{"id":"global-access-roadmap","name":"Global access and affordability roadmap: essential medicines and generics → biosimilars and frugal trials → reliance, pooling and homegrown innovation","route":"/roadmaps/global-access-roadmap/","eras":[{"era":"1977-2012","title":"Essential medicines, generics and the compulsory licence","description":"The WHO Essential Medicines List, first published in 1977, told health systems what to buy first; India's process-patent regime and companies such as Cipla, Natco and Dr Reddy's supplied the generics; and when a patented liver cancer drug was priced beyond reach, India issued its first compulsory licence (Natco v Bayer, 2012). Tobacco control, hepatitis B vaccination and cheap curative chemotherapy for childhood leukaemia and testicular cancer were the interventions that travelled.","status":"historic","refs":[{"id":"who-essential-medicines","kind":"term","name":"WHO Essential Medicines List for cancer","route":"/terms/who-essential-medicines/","tldr":"The World Health Organization's list of medicines every health system should provide, which now includes about 60 cancer drugs from cyclophosphamide and cisplatin to trastuzumab, imatinib and PD-1 inhibitors, guiding procurement and pricing in lower-income countries."},{"id":"who","kind":"institution","name":"World Health Organization Cancer Programme","route":"/institutions/who/","tldr":"The UN health agency that sets global cancer policy: the cervical cancer elimination strategy, the essential medicines list, the childhood cancer initiative and the classification of tumours."},{"id":"cipla","kind":"company","name":"Cipla","route":"/companies/cipla/","tldr":"The Mumbai generics maker famous for a one-dollar-a-day HIV regimen, which sells oncology generics across India and Africa and in 2026 partnered with ImmunoACT to take Indian CAR-T therapy to Africa."},{"id":"natco","kind":"company","name":"Natco Pharma","route":"/companies/natco/","tldr":"The oncology generics company at the centre of India's two landmark patent fights: the first compulsory licence, for sorafenib in 2012, and the Supreme Court's 2013 refusal of Novartis's imatinib patent."},{"id":"dr-reddys","kind":"company","name":"Dr. Reddy's Laboratories","route":"/companies/dr-reddys/","tldr":"The Hyderabad generics maker that launched the world's first rituximab biosimilar in 2007 and now sells oncology generics and biosimilars in India, the US and Europe."},{"id":"sun-pharma","kind":"company","name":"Sun Pharmaceutical Industries","route":"/companies/sun-pharma/","tldr":"India's largest drug company, which owns the branded cancer drugs Odomzo and Yonsa in the US and bought the PD-L1 antibody maker Checkpoint Therapeutics in 2025."},{"id":"global-oncology-access","kind":"technology","name":"Global oncology and access in low- and middle-income countries","route":"/technologies/global-oncology-access/","status":"emerging","tldr":"Seventy percent of cancer deaths occur in low- and middle-income countries, where radiotherapy machines, pathologists, essential medicines and palliative care are scarce. Global oncology works on affordable, adapted care and the systems to deliver it."},{"id":"b-global-access","kind":"bottleneck","name":"Most of the world has almost no cancer care","route":"/bottlenecks/b-global-access/","tldr":"Seven in ten cancer deaths happen in low- and middle-income countries, where radiotherapy, pathology, surgery and drugs are scarce."}],"trials":[],"papers":[]},{"era":"2012-2020","title":"Biosimilars and pooled procurement","description":"Trastuzumab biosimilars, approved from 2017 with Biocon and Mylan's first, and rituximab biosimilars cut the price of two of the most important cancer antibodies by large fractions where they were adopted; in Europe, biosimilar-first defaults did most of the work. India's National Cancer Grid, run from Tata Memorial and linking more than 360 centres, showed that pooled procurement across hospitals lowers prices further and standardises what is bought.","status":"historic","refs":[{"id":"trastuzumab-biosimilars","kind":"drug","name":"Trastuzumab biosimilars","route":"/drugs/trastuzumab-biosimilars/","status":"approved","tldr":"Near-identical copies of Herceptin, approved since 2017, that cut the price of HER2 treatment and widened access worldwide."},{"id":"biosimilar","kind":"term","name":"Biosimilar","route":"/terms/biosimilar/","tldr":"A biosimilar is a copy of a biologic drug such as trastuzumab, shown to be as safe and effective as the original once its patent expires, usually at a lower price."},{"id":"biocon","kind":"company","name":"Biocon","route":"/companies/biocon/","tldr":"India's largest biopharmaceutical company, founded by Kiran Mazumdar-Shaw in 1978, and the parent of Biocon Biologics, which makes low-cost copies of the antibodies trastuzumab and bevacizumab."},{"id":"biocon-biologics","kind":"company","name":"Biocon Biologics","route":"/companies/biocon-biologics/","tldr":"Biocon's biosimilars arm, one of the few companies outside the US and Europe with FDA- and EMA-approved cancer antibody biosimilars, and since 2022 the owner of Viatris's biosimilars business."},{"id":"intas","kind":"company","name":"Intas Pharmaceuticals (Accord Healthcare)","route":"/companies/intas/","tldr":"A privately held Ahmedabad company whose European arm, Accord Healthcare, is one of the largest suppliers of generic chemotherapy and supportive-care biosimilars to European hospitals."},{"id":"zydus","kind":"company","name":"Zydus Lifesciences","route":"/companies/zydus/","tldr":"Zydus Lifesciences, a large Ahmedabad drug maker founded in 1952, sells oncology generics and biosimilars in India and won US approval in October 2024 for generic enzalutamide, a hormone-blocking pill for prostate cancer. Its US generics pipeline is the route by which Indian manufacturing pressure reaches cancer drug prices."},{"id":"national-cancer-grid","kind":"institution","name":"National Cancer Grid of India","route":"/institutions/national-cancer-grid/","tldr":"A network of more than 360 Indian cancer centres, run from Tata Memorial, that agrees common treatment guidelines, buys cancer drugs together at a fraction of list price and runs shared tumour boards and trials."},{"id":"tata-memorial","kind":"institution","name":"Tata Memorial Centre","route":"/institutions/tata-memorial/","tldr":"India's largest cancer centre, a leader in low-cost, high-impact trials such as low-dose immunotherapy and oral metronomic chemotherapy."},{"id":"tata-trusts","kind":"institution","name":"Tata Trusts","route":"/institutions/tata-trusts/","tldr":"India's oldest philanthropic trusts, which built the Tata Memorial Hospital in 1941 and since 2017 have been building a network of 20 cancer hospitals across seven states so that treatment is closer to home."},{"id":"paper-pramesh-ncg-pooled-procurement-2023","kind":"paper","name":"A National Cancer Grid pooled procurement initiative, India","route":"/key-papers/paper-pramesh-ncg-pooled-procurement-2023/","tldr":"When 23 Indian cancer centres bought 40 cancer drugs together instead of separately, prices fell by a median of 82%, saving about 13 billion rupees against list prices."},{"id":"idea-reg-biosimilar-first-default-switching","kind":"idea","name":"Biosimilar-first defaults and payment parity in every cancer day unit","route":"/ideas/idea-reg-biosimilar-first-default-switching/","tldr":"Cheaper copies of biological cancer drugs exist but are used far less in some countries than others. Making them the default choice saves billions with no loss of benefit."}],"trials":[],"papers":[{"id":"paper-pramesh-ncg-pooled-procurement-2023","name":"A National Cancer Grid pooled procurement initiative, India","route":"/key-papers/paper-pramesh-ncg-pooled-procurement-2023/","journal":"Bulletin of the World Health Organization","year":2023,"whatItMeans":"Buying power, not new science, is the fastest lever on cancer drug prices in a decentralised, under-funded system. The Grid's model is being extended across its 360-plus centres and offers a template for other middle-income countries and for pooled buying of newer, patented drugs."}]},{"era":"2015-2026","title":"Frugal evidence: less drug, cheaper schedules, same result","description":"Tata Memorial randomised the questions no company would fund: about a twentieth of a nivolumab dose added to cheap oral metronomic chemotherapy improved survival in head and neck cancer, oral metronomic tablets matched intravenous cisplatin, a single depot progesterone injection before breast surgery helped, and elective neck dissection was proven over watchful waiting. In the UK, PERSEPHONE showed six months of trastuzumab is nearly as good as twelve with half the heart toxicity, FAST-Forward cut breast radiotherapy to one week, and INTERLACE cut cervical cancer deaths with six weeks of generic chemotherapy. Each is usable anywhere; the task is getting them into labels and guidelines.","status":"current","refs":[{"id":"low-dose-nivolumab-tmh","kind":"trial","name":"Low-dose nivolumab plus metronomic chemotherapy (Tata Memorial)","route":"/trials/low-dose-nivolumab-tmh/","status":"positive","tldr":"A Mumbai trial that added about one-twentieth of the usual dose of the immunotherapy nivolumab to cheap oral chemotherapy and nearly tripled the share of patients alive at one year."},{"id":"paper-patil-low-dose-nivolumab-jco-2023","kind":"paper","name":"Low-dose immunotherapy in head and neck cancer: a randomised study (Tata Memorial)","route":"/key-papers/paper-patil-low-dose-nivolumab-jco-2023/","tldr":"Giving about one-twentieth of the standard dose of nivolumab alongside cheap oral chemotherapy nearly tripled one-year survival in advanced head and neck cancer, showing that immunotherapy can be made affordable without losing its effect."},{"id":"metronomic-vs-cisplatin-tmh","kind":"trial","name":"Oral metronomic chemotherapy vs intravenous cisplatin (Tata Memorial)","route":"/trials/metronomic-vs-cisplatin-tmh/","status":"positive","tldr":"Two cheap tablets taken at home matched, and in fact beat, intravenous cisplatin for advanced head and neck cancer in a 422-patient Indian trial, with fewer side effects."},{"id":"metro-plus-varanasi","kind":"trial","name":"METRO PLUS (Tata Memorial Centre, Varanasi)","route":"/trials/metro-plus-varanasi/","status":"positive","tldr":"Adding low-cost oral metronomic tablets to standard paclitaxel-carboplatin doubled median survival from 5 to 10 months in a randomised trial run in Varanasi."},{"id":"progesterone-preop-tmh","kind":"trial","name":"Single-injection depot progesterone before breast surgery (Tata Memorial)","route":"/trials/progesterone-preop-tmh/","status":"mixed","tldr":"A single cheap hormone injection before breast surgery did not help every woman, but in those whose cancer had reached the lymph nodes it improved survival at five years, a finding still being tested."},{"id":"elective-neck-dissection-tmh","kind":"trial","name":"Elective vs therapeutic neck dissection in node-negative oral cancer (Tata Memorial)","route":"/trials/elective-neck-dissection-tmh/","status":"positive","tldr":"A Tata Memorial trial ended a 50-year debate by showing that removing the neck lymph nodes at the first operation for early mouth cancer raises three-year survival from about two-thirds to four-fifths."},{"id":"persephone","kind":"trial","name":"PERSEPHONE","route":"/trials/persephone/","status":"positive","tldr":"Six months of trastuzumab was almost as good as twelve, with half the heart toxicity, though twelve remains the global standard."},{"id":"hypofractionation","kind":"term","name":"Hypofractionation (fewer, larger radiotherapy doses)","route":"/terms/hypofractionation/","tldr":"Giving radiotherapy in fewer, bigger daily doses (fractions) so a course takes one to three weeks instead of five to seven. Randomised trials showed equal control and side effects in breast (START, FAST-Forward) and prostate (CHHiP, PACE-B) cancer, and a single dose suffices for bone pain; adoption lags where health systems are paid per fraction."},{"id":"interlace","kind":"trial","name":"INTERLACE","route":"/trials/interlace/","status":"positive","tldr":"Six weeks of cheap, generic chemotherapy before standard chemoradiation cut deaths by 40%, an advance usable anywhere in the world."},{"id":"idea-tr1-low-dose-immunotherapy-for-lmic","kind":"idea","name":"Confirm ultra-low-dose immunotherapy so it can be afforded where most patients live","route":"/ideas/idea-tr1-low-dose-immunotherapy-for-lmic/","tldr":"A single-centre trial at Tata Memorial found that adding nivolumab at about a twentieth of the usual dose to chemotherapy improved outcomes in head and neck cancer. Confirmatory trials against standard-dose immunotherapy are needed before low-dose labels could make immunotherapy affordable for millions."},{"id":"idea-reg-metronomic-lmic-phase3-to-label","kind":"idea","name":"Validate low-cost metronomic oral regimens in phase 3 and carry them into guidelines","route":"/ideas/idea-reg-metronomic-lmic-phase3-to-label/","tldr":"Indian trials have shown that tiny daily doses of old oral chemotherapy drugs can help patients with head and neck cancer at a cost of a few dollars a month. These regimens should be proven and adopted worldwide."},{"id":"idea-acc-metronomic-lmic-platform-trial","kind":"idea","name":"A platform trial of very-low-cost metronomic chemotherapy in LMIC common cancers","route":"/ideas/idea-acc-metronomic-lmic-platform-trial/","tldr":"Frequent tiny doses of cheap old chemotherapy pills have shown surprising benefit in some cancers. A single large trial network in India and Africa could find out where this works and where it does not."},{"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/","tldr":"The PERSEPHONE trial showed six months of trastuzumab after surgery is as good as twelve, halving the drug cost; no company will run such trials, so public funders and charities must."},{"id":"idea-reg-public-deescalation-trials-for-cost","kind":"idea","name":"Publicly funded trials of lower and less frequent doses of expensive cancer drugs","route":"/ideas/idea-reg-public-deescalation-trials-for-cost/","tldr":"Abiraterone at a quarter dose with food matches full-dose exposure, and pembrolizumab and nivolumab can be given at longer intervals, but no manufacturer will fund trials that cut its own revenue. A public 'value trials' fund would run non-inferiority trials of lower doses and longer intervals for the highest-spend cancer drugs, with payers committing to adopt positive results."}],"trials":[{"id":"low-dose-nivolumab-tmh","name":"Low-dose nivolumab plus metronomic chemotherapy (Tata Memorial)","route":"/trials/low-dose-nivolumab-tmh/","outcomes":[{"endpoint":"Overall survival at 1 year","primary":true,"unit":"%","arms":[{"name":"Metronomic chemotherapy + low-dose nivolumab","n":76,"value":43.4},{"name":"Metronomic chemotherapy","n":75,"value":16.3}],"hr":0.545,"ci":[0.362,0.82],"p":"0.0036","source":"https://doi.org/10.1200/JCO.22.01015"},{"endpoint":"Median overall survival","unit":"months","arms":[{"name":"Metronomic chemotherapy + low-dose nivolumab","value":10.1},{"name":"Metronomic chemotherapy","value":6.7}],"source":"https://doi.org/10.1200/JCO.22.01015"}],"setting":"Recurrent or newly diagnosed advanced head and neck squamous cell carcinoma, palliative intent: triple oral metronomic chemotherapy with or without nivolumab 20 mg every 3 weeks","enrolled":151,"enrolledBasis":"registry"},{"id":"metronomic-vs-cisplatin-tmh","name":"Oral metronomic chemotherapy vs intravenous cisplatin (Tata Memorial)","route":"/trials/metronomic-vs-cisplatin-tmh/","outcomes":[{"endpoint":"Median overall survival","primary":true,"unit":"months","arms":[{"name":"Oral metronomic (methotrexate + celecoxib)","n":213,"value":7.5},{"name":"IV cisplatin","n":209,"value":6.1}],"hr":0.773,"ci":[0.615,0.97],"p":"0.026","source":"https://doi.org/10.1016/S2214-109X(20)30275-8"}],"setting":"Recurrent, metastatic or inoperable head and neck carcinoma, palliative intent: oral methotrexate 15 mg/m2 weekly plus celecoxib 200 mg twice daily vs intravenous cisplatin","enrolled":422,"enrolledBasis":"registry"},{"id":"metro-plus-varanasi","name":"METRO PLUS (Tata Memorial Centre, Varanasi)","route":"/trials/metro-plus-varanasi/","outcomes":[{"endpoint":"Median overall survival","primary":true,"unit":"months","arms":[{"name":"Paclitaxel-carboplatin + oral metronomic chemotherapy","n":119,"value":10},{"name":"Paclitaxel-carboplatin","n":119,"value":5}],"hr":0.54,"ci":[0.41,0.72],"p":"<0.001","source":"https://doi.org/10.1200/GO-25-00721"}],"setting":"Advanced unresectable head and neck cancer: paclitaxel-carboplatin with or without oral metronomic chemotherapy","enrolled":238,"enrolledBasis":"registry"},{"id":"progesterone-preop-tmh","name":"Single-injection depot progesterone before breast surgery (Tata Memorial)","route":"/trials/progesterone-preop-tmh/","outcomes":[{"endpoint":"5-year disease-free survival, node-positive subgroup","unit":"%","arms":[{"name":"Progesterone","value":65.3},{"name":"Control","value":54.7}],"hr":0.72,"ci":[0.54,0.97],"p":"0.02","source":"https://doi.org/10.1200/JCO.2010.33.0738"}],"setting":"Operable breast cancer: one intramuscular injection of hydroxyprogesterone 5 to 14 days before surgery vs no injection","enrolled":976,"enrolledBasis":"registry"},{"id":"elective-neck-dissection-tmh","name":"Elective vs therapeutic neck dissection in node-negative oral cancer (Tata Memorial)","route":"/trials/elective-neck-dissection-tmh/","outcomes":[{"endpoint":"3-year overall survival","primary":true,"unit":"%","arms":[{"name":"Elective neck dissection","n":245,"value":80},{"name":"Therapeutic neck dissection","n":255,"value":67.5}],"hr":0.64,"ci":[0.45,0.92],"p":"0.01","source":"https://doi.org/10.1056/NEJMoa1506007"}],"setting":"Early-stage (T1-T2) node-negative oral squamous cell cancer: elective neck dissection at primary surgery vs watchful waiting with therapeutic dissection at nodal relapse","enrolled":596,"enrolledNote":"ClinicalTrials.gov lists an estimated 710 participants and the record's status is unknown, meaning the sponsor has not verified it recently; the NEJM 2015 paper reports 596 patients enrolled between 2004 and 2014, with the first 500 analysed.","enrolledBasis":"registered"},{"id":"persephone","name":"PERSEPHONE","route":"/trials/persephone/","outcomes":[{"endpoint":"4-year disease-free survival","primary":true,"unit":"%","arms":[{"name":"6 months trastuzumab","n":2043,"value":89.4},{"name":"12 months trastuzumab","n":2045,"value":89.8}],"hr":1.07,"ci":[0.93,1.24],"source":"https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30650-6/fulltext"}],"setting":"Adjuvant HER2+ early breast cancer: 6 vs 12 months of trastuzumab","enrolled":4088,"enrolledBasis":"registry"},{"id":"interlace","name":"INTERLACE","route":"/trials/interlace/","outcomes":[{"endpoint":"Progression-free survival at 5 years","primary":true,"unit":"%","arms":[{"name":"Induction chemo + CRT","n":250,"value":72},{"name":"CRT alone","n":250,"value":64}],"hr":0.65,"ci":[0.46,0.91],"source":"https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01438-7/fulltext"},{"endpoint":"Overall survival at 5 years","primary":true,"unit":"%","arms":[{"name":"Induction chemo + CRT","value":80},{"name":"CRT alone","value":72}],"hr":0.6,"ci":[0.4,0.91],"source":"https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01438-7/fulltext"}],"setting":"Locally advanced cervical cancer: 6 weeks of induction carboplatin-paclitaxel before chemoradiation vs chemoradiation alone","enrolled":500,"enrolledBasis":"registry"}],"papers":[{"id":"paper-patil-low-dose-nivolumab-jco-2023","name":"Low-dose immunotherapy in head and neck cancer: a randomised study (Tata Memorial)","route":"/key-papers/paper-patil-low-dose-nivolumab-jco-2023/","journal":"Journal of Clinical Oncology","year":2023,"whatItMeans":"For the majority of the world's head and neck cancer patients who cannot afford full-dose checkpoint inhibitors, a low dose added to oral metronomic chemotherapy is a tested alternative that improves survival. It also challenges the assumption that approved doses are the necessary doses: pharmacology had long suggested receptor saturation at far lower exposures."}]},{"era":"2018-2026","title":"Homegrown innovation in India and China","description":"India approved its first CAR-T, NexCAR19, developed at IIT Bombay and Tata Memorial and priced at a fraction of Western products; Immuneel ran the first industry CAR-T trial in India; the Serum Institute launched an Indian HPV vaccine. China's PD-1 antibodies (sintilimab, camrelizumab, toripalimab) were approved domestically at prices set by national negotiation and then taken global; its CAR-Ts and HER2 ADCs followed; and ivonescimab became the first drug to beat pembrolizumab head to head (HARMONi-2). The centre of gravity of affordable innovation is moving.","status":"current","refs":[{"id":"talicabtagene-autoleucel","kind":"drug","name":"Talicabtagene autoleucel","route":"/drugs/talicabtagene-autoleucel/","status":"approved","tldr":"India's first home-grown CAR-T cell therapy, approved in 2023 for relapsed leukaemia and lymphoma, made in Mumbai for roughly a tenth of what the same kind of treatment costs in the US."},{"id":"talicel-phase-1-2","kind":"trial","name":"Talicabtagene autoleucel (NexCAR19) phase 1/2","route":"/trials/talicel-phase-1-2/","status":"positive","tldr":"The trial behind India's first CAR-T approval: about three in four heavily pretreated patients with lymphoma or leukaemia responded to a therapy made in Mumbai."},{"id":"immunoact","kind":"company","name":"ImmunoACT","route":"/companies/immunoact/","tldr":"The IIT Bombay spin-off that won India's first CAR-T approval in 2023 with NexCAR19 and has treated more than 600 patients at a tenth of Western prices."},{"id":"varnimcabtagene-autoleucel","kind":"drug","name":"Varnimcabtagene autoleucel","route":"/drugs/varnimcabtagene-autoleucel/","status":"approved","tldr":"India's second approved CAR-T therapy, a Bengaluru-made version of a Spanish hospital's academic CD19 cell therapy, for lymphoma that has come back after other treatments."},{"id":"imagine-varnimcabtagene","kind":"trial","name":"IMAGINE (varnimcabtagene autoleucel, Immuneel)","route":"/trials/imagine-varnimcabtagene/","status":"positive","tldr":"The first industry-run CAR-T trial in India, testing a Bengaluru-made version of a Barcelona hospital's cell therapy in relapsed lymphoma and leukaemia; it led to the approval of Qartemi."},{"id":"immuneel","kind":"company","name":"Immuneel Therapeutics","route":"/companies/immuneel/","tldr":"A Bengaluru cell therapy company that brought Barcelona's academic CD19 CAR-T to India as Qartemi, the country's second approved CAR-T, after the IMAGINE trial."},{"id":"cervavac","kind":"drug","name":"CERVAVAC (quadrivalent HPV vaccine, India)","route":"/drugs/cervavac/","status":"approved","tldr":"India's first home-made HPV vaccine, protecting against the two virus types that cause most cervical cancers and the two that cause genital warts, at a price meant for a national programme."},{"id":"serum-institute-of-india","kind":"company","name":"Serum Institute of India","route":"/companies/serum-institute-of-india/","tldr":"The world's largest vaccine maker by doses, which developed CERVAVAC, India's first home-made HPV vaccine, so that cervical cancer prevention no longer depends on imported shots."},{"id":"sintilimab","kind":"drug","name":"Sintilimab","route":"/drugs/sintilimab/","status":"approved","tldr":"Sintilimab is Innovent's PD-1 antibody, approved in China since 2018 for Hodgkin lymphoma and then, on the ORIENT trials, for first-line lung, liver, oesophageal and stomach cancer. In 2022 the FDA rejected its lung cancer application because a China-only trial against chemotherapy did not fit US practice, defining the agency's stance on single-country data."},{"id":"innovent","kind":"company","name":"Innovent Biologics","route":"/companies/innovent/","tldr":"Innovent makes sintilimab, China's best-selling PD-1 antibody, and has become a source of next-generation assets for Roche and Takeda."},{"id":"orient-11","kind":"trial","name":"ORIENT-11","route":"/trials/orient-11/","status":"positive","tldr":"The trial that made sintilimab a first-line lung cancer treatment in China, and the one the FDA later refused to accept as evidence for US patients."},{"id":"camrelizumab","kind":"drug","name":"Camrelizumab","route":"/drugs/camrelizumab/","status":"approved","tldr":"Camrelizumab is Jiangsu Hengrui's humanised PD-1 antibody, approved in China for oesophageal, liver and lung cancer but not in the US, where its liver cancer combination with rivoceranib drew complete response letters in 2024 and 2025 over manufacturing and inspection issues. Its signature side effect is reactive cutaneous capillary endothelial proliferation, a skin reaction seen in most patients."},{"id":"hengrui","kind":"company","name":"Jiangsu Hengrui Pharmaceuticals","route":"/companies/hengrui/","tldr":"Jiangsu Hengrui is China's largest oncology pharma, maker of pyrotinib and the HER2 ADC trastuzumab rezetecan, and one of the biggest out-licensers of Chinese assets."},{"id":"junshi","kind":"company","name":"Shanghai Junshi Biosciences","route":"/companies/junshi/","tldr":"Junshi developed toripalimab, the first Chinese PD-1 antibody approved in China (2018) and the first approved by the FDA (2023, nasopharyngeal cancer)."},{"id":"relmacabtagene-autoleucel","kind":"drug","name":"Relmacabtagene autoleucel","route":"/drugs/relmacabtagene-autoleucel/","status":"approved","tldr":"Relma-cel was the first CAR-T therapy developed and made in China to be approved, for large B-cell lymphoma that has come back after two treatments."},{"id":"reliance","kind":"trial","name":"RELIANCE","route":"/trials/reliance/","status":"positive","tldr":"The trial that made relma-cel the first CAR-T developed and manufactured in China to be approved, with three quarters of patients responding."},{"id":"trastuzumab-rezetecan","kind":"drug","name":"Trastuzumab rezetecan","route":"/drugs/trastuzumab-rezetecan/","status":"approved","tldr":"Hengrui's HER2 ADC, approved in China for lung cancer and showing Enhertu-scale results in breast cancer, part of a wave of Chinese ADCs heading for global trials."},{"id":"harmoni-2","kind":"trial","name":"HARMONi-2","route":"/trials/harmoni-2/","status":"positive","tldr":"The first head-to-head trial in which a new drug beat Keytruda, in China; a survival benefit followed in 2026."},{"id":"nhsa","kind":"institution","name":"National Healthcare Security Administration","route":"/institutions/nhsa/","tldr":"The NHSA runs China's public health insurance and negotiates once a year which new cancer drugs are reimbursed, and at what price, through the National Reimbursement Drug List."},{"id":"csco-guidelines","kind":"collection","name":"CSCO guidelines (China)","route":"/collections/csco-guidelines/","tldr":"CSCO guidelines are China's national oncology guidelines, covering about 30 cancers and updated annually. They grade each recommendation by both evidence level and affordability under China's reimbursement list, and they cover Chinese-developed drugs (PD-1 inhibitors, ADCs) and cancers common in China (nasopharyngeal, oesophageal, liver, gastric) years before Western guidelines."}],"trials":[{"id":"talicel-phase-1-2","name":"Talicabtagene autoleucel (NexCAR19) phase 1/2","route":"/trials/talicel-phase-1-2/","outcomes":[{"endpoint":"Overall response rate","primary":true,"unit":"%","arms":[{"name":"Talicabtagene autoleucel","n":51,"value":73,"note":"95% CI 59-83"}],"source":"https://doi.org/10.1016/S2352-3026(24)00377-6"}],"setting":"Relapsed or refractory B-cell lymphoma and B-cell acute lymphoblastic leukaemia, adults and adolescents, six Indian tertiary centres","enrolled":64,"enrolledBasis":"registry"},{"id":"imagine-varnimcabtagene","name":"IMAGINE (varnimcabtagene autoleucel, Immuneel)","route":"/trials/imagine-varnimcabtagene/","outcomes":[{"endpoint":"Overall response rate at the primary endpoint","primary":true,"unit":"%","arms":[{"name":"Varnimcabtagene autoleucel (IMN-003A)","n":21,"value":80.9,"note":"17 of 21 evaluable patients (B-cell NHL and B-ALL combined); 24 infused; median PFS not reached at the ASH 2023 cut, relapse in 9 of 24"}],"source":"https://doi.org/10.1182/blood-2023-181120"},{"endpoint":"Cytokine release syndrome, any grade","unit":"%","arms":[{"name":"Varnimcabtagene autoleucel (IMN-003A)","n":24,"value":66.7,"note":"Grade 1 in 62.5%, grade 3 or higher in 4.2%; ICANS 4.2% (grade 1 only)"}],"source":"https://doi.org/10.1182/blood-2023-181585"}],"setting":"Relapsed or refractory B-cell malignancies (B-cell non-Hodgkin lymphoma and B-ALL), adults, India","enrolled":24,"enrolledBasis":"registry"},{"id":"orient-11","name":"ORIENT-11","route":"/trials/orient-11/","outcomes":[{"endpoint":"Progression-free survival","primary":true,"unit":"months","arms":[{"name":"Sintilimab + pemetrexed-platinum","n":266,"value":8.9},{"name":"Placebo + pemetrexed-platinum","n":131,"value":5}],"hr":0.482,"source":"https://doi.org/10.1016/j.jtho.2020.07.014"}],"setting":"First-line non-squamous NSCLC without EGFR or ALK alterations, China: sintilimab or placebo plus pemetrexed and platinum","enrolled":397,"enrolledBasis":"registry"},{"id":"reliance","name":"RELIANCE","route":"/trials/reliance/","outcomes":[{"endpoint":"Objective response rate","primary":true,"unit":"%","arms":[{"name":"Relma-cel (both dose levels)","n":59,"value":75.9}],"source":"https://doi.org/10.1002/cam4.3686"}],"setting":"Relapsed or refractory large B-cell lymphoma after two or more lines, China: single-arm pivotal study of relmacabtagene autoleucel at two dose levels","enrolled":59,"enrolledBasis":"registry"},{"id":"harmoni-2","name":"HARMONi-2","route":"/trials/harmoni-2/","outcomes":[{"endpoint":"Progression-free survival (IRRC)","primary":true,"unit":"months","arms":[{"name":"Ivonescimab","n":198,"value":11.1},{"name":"Pembrolizumab","n":200,"value":5.8}],"hr":0.51,"ci":[0.38,0.69],"p":"<0.0001","source":"https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02722-3/fulltext"}],"setting":"First-line PD-L1-positive (TPS ≥1%) advanced NSCLC in China: ivonescimab vs pembrolizumab monotherapy","enrolled":398,"enrolledBasis":"registry"}],"papers":[]},{"era":"2000s-2026","title":"Screening and prevention that fit the budget","description":"One round of HPV testing in rural Indian villages cut cervical cancer deaths (Osmanabad); trained health workers with a torch found mouth cancers early in tobacco users (Kerala); vinegar and a lamp screened women in Mumbai slums. A single HPV vaccine dose proved almost fully protective (an interrupted Indian trial, then KEN SHE), and self-collected swabs with same-day thermal ablation let nurses run cervical programmes without colposcopy. These are the interventions with the highest return per dollar in oncology.","status":"current","refs":[{"id":"osmanabad-hpv-screening","kind":"trial","name":"Osmanabad cervical screening trial (HPV testing vs cytology vs VIA)","route":"/trials/osmanabad-hpv-screening/","status":"positive","tldr":"One round of HPV testing in rural Indian villages halved deaths from cervical cancer within eight years, while a Pap smear or a visual check did not, which is why HPV tests are now the world's preferred screen."},{"id":"kerala-oral-screening","kind":"trial","name":"Kerala oral cancer visual screening trial (Trivandrum)","route":"/trials/kerala-oral-screening/","status":"positive","tldr":"Trained health workers looking inside the mouths of tobacco and alcohol users in Kerala cut oral cancer deaths by a third, and by four-fifths in those who came to every screening round."},{"id":"oral-visual-screening","kind":"technology","name":"Oral cancer visual screening","route":"/technologies/oral-visual-screening/","status":"established","tldr":"A trained health worker looking inside the mouth with a light can find mouth cancer early; in India this cut deaths by a third among people who use tobacco or alcohol."},{"id":"mumbai-via-screening","kind":"trial","name":"Mumbai VIA cervical screening trial (Tata Memorial)","route":"/trials/mumbai-via-screening/","status":"positive","tldr":"Health workers with a torch and vinegar, screening women in Mumbai's slums every two years, cut cervical cancer deaths by 31% in a trial of more than 150,000 women."},{"id":"iarc-india-hpv-dose-study","kind":"trial","name":"IARC India HPV vaccine dose study (one, two or three doses)","route":"/trials/iarc-india-hpv-dose-study/","status":"positive","tldr":"When an Indian vaccine trial was halted midway, thousands of girls had had only one shot; following them for ten years showed one dose protected as well as three, changing the world's vaccination policy."},{"id":"ken-she","kind":"trial","name":"KEN SHE (single-dose HPV vaccine)","route":"/trials/ken-she/","status":"positive","tldr":"One shot of HPV vaccine was 97.5% effective against the two most dangerous HPV types, making it realistic to vaccinate the whole world."},{"id":"hpv-testing","kind":"technology","name":"HPV DNA testing and self-sampling","route":"/technologies/hpv-testing/","status":"standard-of-care","tldr":"A swab tested for the virus that causes cervical cancer, more accurate than the Pap smear and doable at home."},{"id":"precancer-ablation","kind":"technology","name":"Thermal ablation and cryotherapy for cervical precancer","route":"/technologies/precancer-ablation/","status":"standard-of-care","tldr":"Destroying precancerous cervical cells with a heated or frozen probe in under a minute, the tool that makes screen-and-treat possible where there are no surgeons."},{"id":"idea-acc-hpv-self-sample-same-day-ablation","kind":"idea","name":"HPV self-testing with same-day treatment as the national cervical programme","route":"/ideas/idea-acc-hpv-self-sample-same-day-ablation/","tldr":"Women can collect their own sample for the virus that causes cervical cancer; those who test positive can be treated the same day with a simple heat device. Done nationally, this could eliminate a disease that still kills hundreds of thousands of women a year."},{"id":"iarc","kind":"institution","name":"International Agency for Research on Cancer (IARC / WHO)","route":"/institutions/iarc/","tldr":"IARC is the WHO's cancer agency, responsible for global cancer statistics (GLOBOCAN), carcinogen classification, and prevention research."},{"id":"prevention-roadmap","kind":"roadmap","name":"Cancer prevention roadmap: tobacco control and vaccines → biomarker-guided chemoprevention → interception in carriers","route":"/roadmaps/prevention-roadmap/","tldr":"About four in ten cancers could be prevented with tools that already exist: vaccines against the viruses that cause them, tobacco and alcohol control, weight, aspirin for the right people, and finding the families who carry a high-risk gene. The roadmap is mostly about deployment, with interception vaccines as the long-range bet."}],"trials":[{"id":"osmanabad-hpv-screening","name":"Osmanabad cervical screening trial (HPV testing vs cytology vs VIA)","route":"/trials/osmanabad-hpv-screening/","outcomes":[{"endpoint":"Cervical cancer deaths","primary":true,"unit":"deaths","arms":[{"name":"HPV testing","n":34126,"value":34},{"name":"Control","n":31488,"value":64}],"hr":0.52,"ci":[0.33,0.83],"source":"https://doi.org/10.1056/NEJMoa0808516"}],"setting":"Cluster-randomised trial in 52 villages of Osmanabad district, Maharashtra: one round of HPV DNA testing, cytology, visual inspection with acetic acid, or usual care in women aged 30-59","enrolled":131746,"enrolledBasis":"registry"},{"id":"kerala-oral-screening","name":"Kerala oral cancer visual screening trial (Trivandrum)","route":"/trials/kerala-oral-screening/","outcomes":[{"endpoint":"Oral cancer mortality, tobacco or alcohol users (rate ratio, 3 rounds)","primary":true,"arms":[{"name":"Visual screening","n":96517,"value":0.66,"note":"Rate ratio vs control; 95% CI 0.45-0.95"}],"source":"https://doi.org/10.1016/S0140-6736(05)66658-5"}],"setting":"Cluster-randomised trial in 13 clusters of Trivandrum district: three (later four) rounds of oral visual inspection by trained health workers vs usual care in adults aged 35 and over","enrolled":191873,"enrolledBasis":"registry"},{"id":"mumbai-via-screening","name":"Mumbai VIA cervical screening trial (Tata Memorial)","route":"/trials/mumbai-via-screening/","outcomes":[{"endpoint":"Cervical cancer mortality (rate ratio)","primary":true,"arms":[{"name":"VIA screening by health workers","n":75360,"value":0.69,"note":"Rate ratio vs control; 95% CI 0.54-0.88"}],"p":"0.003","source":"https://doi.org/10.1093/jnci/dju009"}],"setting":"Cluster-randomised trial in 20 slum clusters of Mumbai: visual inspection with acetic acid by trained primary health workers every 2 years vs health education, women aged 35-64","enrolled":151538,"enrolledBasis":"registry"},{"id":"iarc-india-hpv-dose-study","name":"IARC India HPV vaccine dose study (one, two or three doses)","route":"/trials/iarc-india-hpv-dose-study/","outcomes":[{"endpoint":"Vaccine efficacy against persistent HPV 16/18 infection","primary":true,"unit":"%","arms":[{"name":"One dose","n":4949,"value":95.4,"note":"95% CI 85.0-99.9"},{"name":"Two doses","n":4980,"value":93.1,"note":"95% CI 77.3-99.8"},{"name":"Three doses","n":4348,"value":93.3,"note":"95% CI 77.5-99.7"}],"source":"https://doi.org/10.1016/S1470-2045(21)00453-8"}],"setting":"Girls aged 10-18 in India randomised to two or three doses of quadrivalent HPV vaccine; after a 2010 suspension of recruitment, cohorts who had received one, two or three doses were followed for a decade","enrolled":17729,"enrolledBasis":"registry"},{"id":"ken-she","name":"KEN SHE (single-dose HPV vaccine)","route":"/trials/ken-she/","outcomes":[{"endpoint":"Vaccine efficacy against persistent HPV16/18 infection","primary":true,"unit":"%","arms":[{"name":"Single dose nonavalent HPV","value":97.5}],"source":"https://www.cdc.gov/acip/downloads/slides-2025-04-15-16/03-Barnabas-HPV-508.pdf"}],"setting":"Kenyan women aged 15-20: single dose of bivalent or nonavalent HPV vaccine vs meningococcal control, endpoint persistent HPV16/18 infection","enrolled":2275,"enrolledBasis":"registry"}],"papers":[]},{"era":"2026-2030","title":"Reliance, pooling and public manufacturing","description":"Project Orbis lets the FDA and partner regulators review together; the proposals extend it to a shared assessment report and a 90-day reliance approval for drugs cleared by two stringent regulators. WHO prequalification plus pooled demand could push biosimilar prices below a tenth of the originator; an advance market commitment could do the same for PD-1 biosimilars; Medicines Patent Pool licences for every patented drug on the essential list and tiered-price pledges tied to listing would formalise it. Public-sector CAR-T manufacturing in India, Brazil and South Africa, pooled procurement of radiotherapy machines with uptime contracts, and a Global Fund for cancer are the capital-intensive versions.","status":"emerging","refs":[{"id":"project-orbis","kind":"term","name":"Project Orbis","route":"/terms/project-orbis/","tldr":"Project Orbis is a scheme where the FDA and partner regulators (Australia, Canada, UK, Switzerland, Singapore, Brazil, Israel) review a cancer drug at the same time."},{"id":"idea-reg-orbis-work-sharing","kind":"idea","name":"Turn Project Orbis into a work-sharing review with one shared assessment report","route":"/ideas/idea-reg-orbis-work-sharing/","tldr":"Regulators in several countries already look at the same cancer drug dossier at the same time. Let them split the work and write one report instead of six."},{"id":"idea-reg-reliance-90-day-lmic","kind":"idea","name":"90-day reliance approval for cancer drugs cleared by two stringent regulators","route":"/ideas/idea-reg-reliance-90-day-lmic/","tldr":"If the FDA and EMA have both approved a cancer drug, a smaller country should be able to approve it in three months using their reports rather than starting over."},{"id":"idea-acc-biosimilar-prequalification-pool","kind":"idea","name":"WHO prequalification plus pooled demand to push biosimilar prices below 10% of the originator","route":"/ideas/idea-acc-biosimilar-prequalification-pool/","tldr":"Biosimilars of trastuzumab, rituximab and bevacizumab have existed for years, but poorer countries cannot assess biologics themselves and place small fragmented orders. Extending WHO prequalification, begun with trastuzumab in 2019, to every oncology biosimilar and pooling procurement would give buyers assurance and makers volume, aiming below a tenth of originator prices."},{"id":"idea-reg-pd1-biosimilar-advance-commitment","kind":"idea","name":"An advance market commitment for PD-1 biosimilars for lower-income countries","route":"/ideas/idea-reg-pd1-biosimilar-advance-commitment/","tldr":"Immunotherapy patents start expiring around 2028. Guaranteeing in advance to buy cheap copies for poorer countries would make sure manufacturers build the capacity."},{"id":"idea-reg-biosimilar-no-efficacy-trial","kind":"idea","name":"Approve cancer biosimilars on analytics and pharmacokinetics, no efficacy trials","route":"/ideas/idea-reg-biosimilar-no-efficacy-trial/","tldr":"Copies of biological cancer drugs are still required to run large trials that rarely change the answer. Dropping them would cut years and tens of millions from each biosimilar."},{"id":"idea-reg-patent-pool-oncology-eml","kind":"idea","name":"Medicines Patent Pool licences for every patented cancer drug on the WHO list","route":"/ideas/idea-reg-patent-pool-oncology-eml/","tldr":"Companies can license their patents to generic makers for poorer countries through a UN-backed pool, as happened for HIV. Only one cancer drug has been licensed so far; the whole essential list should be."},{"id":"idea-acc-eml-listing-price-commitments","kind":"idea","name":"Tie WHO essential-medicines listing to a published tiered price and supply pledge","route":"/ideas/idea-acc-eml-listing-price-commitments/","tldr":"When a cancer drug is added to the WHO essential medicines list, the maker should publicly commit to a low price and reliable supply for poorer countries, or the listing is withheld."},{"id":"idea-reg-tiered-pricing-for-exclusivity","kind":"idea","name":"Grant extra exclusivity only in exchange for binding low prices in poorer countries","route":"/ideas/idea-reg-tiered-pricing-for-exclusivity/","tldr":"Companies get longer monopolies for rare and paediatric cancer drugs. That reward should come with a commitment to sell at cost in low-income countries."},{"id":"idea-reg-lmic-public-cart-manufacturing","kind":"idea","name":"Public-sector CAR-T manufacturing in India, Brazil and South Africa under $50,000","route":"/ideas/idea-reg-lmic-public-cart-manufacturing/","tldr":"India has shown CAR-T can be made for a tenth of the US price. Public production in large middle-income countries could make it available to millions who are currently excluded."},{"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/","tldr":"Academic hospitals can already make CAR-T cells for a fraction of the commercial price. A public network would scale that so more patients can be treated for less."},{"id":"idea-acc-pooled-procurement-radiotherapy","kind":"idea","name":"A Gavi-style pooled purchaser for radiotherapy equipment and service","route":"/ideas/idea-acc-pooled-procurement-radiotherapy/","tldr":"Countries buying radiotherapy machines one at a time pay high prices and get poor service. A single global buyer negotiating for dozens of machines a year could cut prices and demand long-term support."},{"id":"idea-acc-linac-uptime-contracts","kind":"idea","name":"Pay for radiotherapy machine uptime, not for the machine","route":"/ideas/idea-acc-linac-uptime-contracts/","tldr":"Governments and donors should buy guaranteed working hours from radiotherapy vendors, with remote monitoring and regional spare-parts depots, instead of buying machines that then sit broken."},{"id":"idea-acc-frugal-hdr-brachytherapy","kind":"idea","name":"Low-cost cobalt-60 brachytherapy for cervical cancer in every regional centre","route":"/ideas/idea-acc-frugal-hdr-brachytherapy/","tldr":"Cervical cancer cannot be cured by external radiotherapy alone; it needs brachytherapy, internal radiation that LMIC radiotherapy centres frequently lack or cannot keep running because iridium-192 sources must be replaced every three months. Cobalt-60 sources last about five years and give equivalent doses, so funding cobalt units for every regional centre closes a well-understood cure gap."},{"id":"idea-acc-hypofractionation-default-lmic","kind":"idea","name":"Make one-week radiotherapy the default in overloaded systems","route":"/ideas/idea-acc-hypofractionation-default-lmic/","tldr":"Giving radiotherapy in five larger doses over one week instead of 15 to 25 smaller doses is non-inferior for cancer control and late toxicity in breast and prostate cancer, and triples the number of patients each machine can treat. The barriers are guideline inertia and payment per fraction, not hardware."},{"id":"idea-fund-global-cancer-fund","kind":"idea","name":"A Global Fund for cancer care in low- and middle-income countries","route":"/ideas/idea-fund-global-cancer-fund/","tldr":"Copy the model that transformed HIV, TB and malaria care: a pooled international fund that pays for radiotherapy machines, pathology labs and essential cancer medicines where there are none."},{"id":"idea-reg-middle-income-negotiation-bloc","kind":"idea","name":"A joint price negotiation bloc for middle-income countries, modelled on Beneluxa","route":"/ideas/idea-reg-middle-income-negotiation-bloc/","tldr":"Small European countries have started negotiating cancer drug prices together. A bloc of large middle-income countries would have far more bargaining power."}],"trials":[],"papers":[]},{"era":"2026-2030","title":"Paying for value in rich countries too","description":"New cancer drugs routinely cost more than a house per year, often for months of benefit, and systems cannot afford them without rationing. The levers: prices anchored to the ESMO and ASCO benefit scales and revisited when survival data mature, a different price for the same drug in different indications, publicly funded de-escalation trials of expensive drugs, biosimilar-first defaults, a non-profit manufacturer for generics in shortage, and screening every patient for financial toxicity as a vital sign. The costs page on this site pairs each driver with what is already being done.","status":"emerging","refs":[{"id":"b-drug-pricing","kind":"bottleneck","name":"Prices and value","route":"/bottlenecks/b-drug-pricing/","tldr":"New cancer drugs routinely cost over $150,000 a year, often for months of benefit. Systems cannot afford them and patients go bankrupt."},{"id":"hta","kind":"term","name":"Health technology assessment (HTA), reimbursement and QALYs","route":"/terms/hta/","tldr":"Approval says a drug works; reimbursement says who will pay. Health technology assessment bodies (NICE, G-BA, PBAC) judge whether the benefit is worth the price, often per quality-adjusted life year, and can delay access for years after approval."},{"id":"nice-guidance","kind":"collection","name":"NICE cancer guidance and technology appraisals (UK)","route":"/collections/nice-guidance/","tldr":"NICE decides which cancer treatments the NHS pays for, publishing for each drug an appraisal of cost per quality-adjusted life year against a threshold of £25,000 to £35,000, plus clinical guidelines. Because the manufacturer models and committee reasoning are public, its decisions serve as an independent view of a drug's value that often diverges from FDA and EMA licensing."},{"id":"src-nice-ta","kind":"collection","name":"NICE technology appraisals","route":"/collections/src-nice-ta/","tldr":"NICE technology appraisals say whether the NHS will pay, and why. They are the most transparent HTA record in the world."},{"id":"esmo-guidelines","kind":"collection","name":"ESMO Clinical Practice Guidelines & MCBS","route":"/collections/esmo-guidelines/","tldr":"The ESMO guidelines are Europe's treatment algorithms, and the ESMO-MCBS scores how much each new drug actually helps."},{"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/","tldr":"Oncology societies already grade how much benefit each new drug gives. Payers should tie the maximum price they pay to that grade."},{"id":"idea-reg-indication-specific-pricing","kind":"idea","name":"Pay a different price for the same cancer drug depending on the indication","route":"/ideas/idea-reg-indication-specific-pricing/","tldr":"One immunotherapy may add years of life in one cancer and weeks in another, yet costs the same. Prices should track the benefit in each use."},{"id":"generic-drug-shortage-response","kind":"technology","name":"Generic oncology drug supply and shortage mitigation","route":"/technologies/generic-drug-shortage-response/","status":"established","tldr":"Keeping cheap, essential chemotherapy drugs like cisplatin available; shortages in 2023 forced rationing in US hospitals."},{"id":"idea-reg-nonprofit-generic-chemo-manufacturer","kind":"idea","name":"A non-profit manufacturer for generic cancer drugs in chronic shortage","route":"/ideas/idea-reg-nonprofit-generic-chemo-manufacturer/","tldr":"Cheap, essential chemotherapy drugs like cisplatin run out because making them is not profitable enough. A non-profit maker could guarantee supply at a fair price."},{"id":"idea-reg-financial-toxicity-vital-sign","kind":"idea","name":"Screen every cancer patient for financial toxicity as a vital sign, with navigation","route":"/ideas/idea-reg-financial-toxicity-vital-sign/","tldr":"Cancer costs push patients into debt and make them skip treatment. Asking about money at every visit, and having someone to help, catches this before it does harm."},{"id":"chemotherapy-roadmap","kind":"roadmap","name":"Chemotherapy roadmap: mustard gas → curative combinations → the warhead inside smarter drugs","route":"/roadmaps/chemotherapy-roadmap/","tldr":"Chemotherapy went from a poison that sometimes worked to the backbone of most cures, and is now being given more precisely: to fewer people, at better doses, and increasingly delivered inside an antibody so that it reaches the tumour and not the whole body."}],"trials":[],"papers":[]},{"era":"2030+","title":"Workforce, pain relief and the data to steer by","description":"Drugs do not treat patients; people do, and most of the world has too few oncologists, pathologists, physicists and nurses. Community health workers trained in triage, navigation and home palliative care, Project ECHO tele-mentoring for district clinicians, remote radiotherapy planning hubs, diaspora tumour boards, and opioid quota reform so morphine reaches people dying of cancer are the workforce answers. A population registry as a condition of every aid programme, burden-matched trial funding and pivotal-trial sites in Africa, South Asia and Latin America would make progress measurable. A ten-dollar blood test for the five cancers that kill most people in poorer countries is the diagnostic bet.","status":"speculative","refs":[{"id":"b-workforce","kind":"bottleneck","name":"Not enough oncologists, nurses, pathologists, physicists","route":"/bottlenecks/b-workforce/","tldr":"The number of people with cancer is rising faster than the workforce trained to treat them."},{"id":"b-palliative","kind":"bottleneck","name":"Pain relief and palliative care are unavailable to most","route":"/bottlenecks/b-palliative/","tldr":"Most people who die of cancer worldwide do so without adequate pain relief."},{"id":"idea-acc-community-health-workers-oncology","kind":"idea","name":"Community health workers trained in cancer triage, navigation and home palliative care","route":"/ideas/idea-acc-community-health-workers-oncology/","tldr":"Millions of community health workers already visit homes for vaccines and maternal care. Training them to recognise cancer warning signs, guide patients through the system and support home pain care would reach people no hospital does."},{"id":"idea-acc-echo-tele-mentoring-oncology","kind":"idea","name":"Project ECHO tele-mentoring for district clinicians managing cancer","route":"/ideas/idea-acc-echo-tele-mentoring-oncology/","tldr":"Project ECHO is a weekly video class where district doctors and nurses present real cases to a specialist team, learn by doing, and build a network. It worked for hepatitis C and could work for cancer."},{"id":"idea-acc-remote-planning-hubs","kind":"idea","name":"Round-the-clock remote treatment-planning hubs for clinics without physicists","route":"/ideas/idea-acc-remote-planning-hubs/","tldr":"Hospitals without enough physicists could upload scans to a shared planning centre, where AI drafts the treatment plan and remote experts finish and check it within a day."},{"id":"telemedicine-teleoncology","kind":"technology","name":"Telemedicine, teleoncology, and telepathology","route":"/technologies/telemedicine-teleoncology/","status":"established","tldr":"Video visits, remote second opinions, and slides reviewed from afar, which let rural and low-resource patients reach specialists."},{"id":"idea-acc-balanced-opioid-policy-reform","kind":"idea","name":"National opioid quota reform so morphine reaches cancer patients","route":"/ideas/idea-acc-balanced-opioid-policy-reform/","tldr":"Most of the world's people who die in cancer pain have no access to morphine, a drug that costs pennies, because of restrictive national rules. Fixing the rules, not inventing new drugs, is the answer."},{"id":"idea-acc-registries-as-aid-condition","kind":"idea","name":"Make a population cancer registry a condition of every cancer aid programme","route":"/ideas/idea-acc-registries-as-aid-condition/","tldr":"You cannot fix what you cannot count. Every donor-funded cancer programme should fund and require a population-based cancer registry so results can be measured over time."},{"id":"idea-fund-lmic-burden-match","kind":"idea","name":"Burden-matched funding for trials led in low- and middle-income countries","route":"/ideas/idea-fund-lmic-burden-match/","tldr":"Seven in ten cancer deaths are in poorer countries, yet almost all trials happen in rich ones. Funders would commit a share of money for trials designed and led where the burden is."},{"id":"idea-tr1-lmic-sites-in-pivotal-trials","kind":"idea","name":"Pivotal trials include sites in Africa, South Asia and Latin America, sponsor-funded","route":"/ideas/idea-tr1-lmic-sites-in-pivotal-trials/","tldr":"Most of the world's cancer patients live in countries that host almost no registrational trials. Including sites there, and paying to build them up, would make results apply globally and speed local access."},{"id":"idea-prev-lmic-five-cancer-methylation-test","kind":"idea","name":"A ten-dollar blood test for the five cancers that kill most people in poorer countries","route":"/ideas/idea-prev-lmic-five-cancer-methylation-test/","tldr":"Most cancer deaths are in low and middle income countries, where scans and endoscopies are scarce. A cheap methylation blood test tuned to liver, stomach, oesophageal, cervical and breast cancer could fill the gap."},{"id":"uicc","kind":"institution","name":"Union for International Cancer Control","route":"/institutions/uicc/","tldr":"The Geneva-based membership body of more than 1,100 cancer organisations that runs World Cancer Day, the World Cancer Congress and the TNM staging system."},{"id":"radiation-roadmap","kind":"roadmap","name":"Radiotherapy roadmap: X-rays → shaped beams → fewer fractions, particles and FLASH","route":"/roadmaps/radiation-roadmap/","tldr":"Radiotherapy cures more people than any drug and has reinvented itself every decade: from crude X-ray fields to beams shaped by computer, delivered in days instead of weeks, and now in fractions of a second. Its future is precision, fewer visits, and combination with drugs that make radiation work better."}],"trials":[],"papers":[]},{"era":"What sets the pace","title":"Pricing power, divergence and the absence of care","description":"Seven in ten cancer deaths happen where radiotherapy, pathology and essential drugs are scarce or absent. Prices are set by what the richest payer will bear, regulators duplicate each other's reviews so approvals lag by years, old cheap drugs have no sponsor to test them, trials rarely include the populations that carry the burden, and most people who die of cancer worldwide do so without adequate pain relief. Every lever above attacks one of these.","status":"current","refs":[{"id":"b-global-access","kind":"bottleneck","name":"Most of the world has almost no cancer care","route":"/bottlenecks/b-global-access/","tldr":"Seven in ten cancer deaths happen in low- and middle-income countries, where radiotherapy, pathology, surgery and drugs are scarce."},{"id":"b-drug-pricing","kind":"bottleneck","name":"Prices and value","route":"/bottlenecks/b-drug-pricing/","tldr":"New cancer drugs routinely cost over $150,000 a year, often for months of benefit. Systems cannot afford them and patients go bankrupt."},{"id":"b-regulatory-fragmentation","kind":"bottleneck","name":"Regulatory divergence between regions","route":"/bottlenecks/b-regulatory-fragmentation/","tldr":"Regulatory divergence means a drug approved in one country can take years to reach another, or never arrive."},{"id":"b-generic-repurposing","kind":"bottleneck","name":"No incentive to repurpose cheap drugs","route":"/bottlenecks/b-generic-repurposing/","tldr":"Old, cheap drugs with anti-cancer signals never get the trials they need because no one profits from the result."},{"id":"b-trial-diversity","kind":"bottleneck","name":"Trials do not represent the people who get cancer","route":"/bottlenecks/b-trial-diversity/","tldr":"Older, Black, Hispanic, Asian, rural, poor and multimorbid patients are under-represented, so results may not apply to them."},{"id":"b-palliative","kind":"bottleneck","name":"Pain relief and palliative care are unavailable to most","route":"/bottlenecks/b-palliative/","tldr":"Most people who die of cancer worldwide do so without adequate pain relief."},{"id":"b-workforce","kind":"bottleneck","name":"Not enough oncologists, nurses, pathologists, physicists","route":"/bottlenecks/b-workforce/","tldr":"The number of people with cancer is rising faster than the workforce trained to treat them."}],"trials":[],"papers":[]}],"watch":[]}