Funding follows fashion, not burden

Gallbladder cancer has been called scantily understood in 2004 and understudied in 2025 by its own researchers. Counting the money spent on it against the deaths it causes, country by country, would make the gap visible and give funders a target.

Cancer kills more people in poorer countries than HIV, TB and malaria combined, but has no global fund. A pooled fund for diagnosis, essential medicines and radiotherapy would change what ministries can afford to build.

Wasting and side-effects kill or stop treatment for a large share of patients but attract almost no dedicated funding. This would create a standing programme for them.

Around four in ten cancers are preventable with tools that exist now. This would fund the hard, unglamorous work of getting vaccines, screening and tobacco control to everyone, paid on results.

Proven treatments, genomic tests and timely referrals routinely fail to reach the patients who qualify for them. Public trial networks such as the NCTN groups, EORTC and the UK NIHR portfolio would have to spend at least 10% of their funding on cluster-randomised or stepped-wedge trials of how to close that gap, cheap studies that use routine data.

Add a scored criterion to grant review that asks how much suffering the proposal addresses and how soon, judged partly by patients, and give it real weight.

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.

Governments promised in advance to buy vaccines that did not yet exist, and they got made. The same promise could be made for a drug against a target everyone has given up on.

No single company will spend a decade on a target that might be impossible. A shared, openly published effort across the twenty hardest targets spreads that risk.

A simple website that shows, every year, how much research money each cancer receives compared with how many people it kills, so the gaps are impossible to ignore.

Old drugs like aspirin, statins and beta-blockers show hints of fighting cancer, but no company will pay to prove it. A dedicated public fund should.

Keep a public list of the questions doctors and patients most need answered but no trial addresses, and tie research funding to it.

Promising academic cancer discoveries stall because nobody funds the expensive step from lab to first human trial. Build a shared public facility that does exactly that step, repeatedly.

Metastasis causes about nine in ten cancer deaths but gets a small slice of research money. This would ring-fence a tenth of national cancer research budgets for the biology and trials of spread itself.

If a cheap old drug could replace or reduce an expensive cancer treatment, health systems save money. Investors could fund the trial and be repaid from those savings if it works.

Surgery and radiotherapy cure more people than drugs but get a fraction of trial funding because there is no company sponsor. A rule would guarantee them a fixed share of public trial money.

Tens of millions of people live after cancer with heart damage, infertility and second cancers. A tiny levy on the price of curative treatments would build a permanent fund to study and treat late effects.

Most people with cancer are over 65, but most trial patients are younger and fitter. A dedicated fund would pay for trials designed for the patients we actually treat.

Mine grant databases and the literature to find cancer types and questions with heavy burden and zero active projects, then publish the list so funders and scientists can go there.

Ask experts and models to predict, in public, which registered combination trials will meet their endpoint. Track who is right, and use the best forecasters to decide what to fund.

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.

Funders would publish how their spending compares with deaths and years of life lost per cancer, and commit to shift a fixed share of money each year towards the biggest gaps.

Governments and philanthropists commit large payments for whoever achieves a verified jump in ten-year cure rates for a specific cancer, however they do it.

Most of the money in cancer goes to treatments that help a few people for a short time, while pain relief for the dying, which is cheap and works, gets almost nothing. Ring-fencing a small fixed share would change that.

Before spending millions on a randomised trial, analyse existing patient records as if the trial had already happened. If the answer is obvious or the question is unanswerable, skip or redesign the trial.

Fast grants for oncology would be a fund that decides within two days on small grants for quick, decisive experiments in cancers or questions that mainstream funders neglect, modelled on the pandemic-era Fast Grants.

A three-year supervised exercise programme after chemotherapy cut recurrence and death by roughly a third in 889 patients, an effect the size of adjuvant chemotherapy. No health system has a funding line for it.

Almost no research money goes to checking whether published cancer findings hold up: one replication project could complete only 23 of 50 planned experiments. Requiring 3 to 5% of every funder's research budget to go to independent replication, published whatever the result, would build the missing feedback loop.

Every survivorship intervention currently raises its own small trial with its own control arm and its own endpoint. A platform trial with a shared control and a common outcome set would test several at the cost of one and a half.

Coaching-based weight loss did not clearly cut breast cancer recurrence in BWEL, perhaps because the weight loss was too small. Drugs that produce three times as much weight loss could settle whether weight itself matters.

The people who run funding programmes are judged on money moved and papers produced. Judge them instead on whether their portfolios match the burden of disease and whether the trials they fund finish.

Every funder that spends more than $50 million a year on cancer research would publish what it funds in a shared, coded database, so gaps and duplication can be seen across the whole system.

Patients with brain tumours are sold ketogenic diets on the strength of mouse data and small feasibility studies. A single adequately powered trial with dietitian support would either prove it or let clinicians say clearly that it does not work.

For cancers too rare or too poor to attract companies, run drug discovery in the open, the way neglected tropical diseases are tackled, and take candidates to first human trials with public money.

Once a proposal in a neglected cancer passes a quality bar, pick winners by lottery instead of by tiny differences in review scores, which mostly reflect fashion.

No company can profit from a drug for a cancer that affects a few hundred people. A guaranteed payment for success would change that calculation.

Nobody knows what a cancer trial should cost because budgets are secret. Publishing anonymised cost per patient by trial type would expose waste and let funders set targets.

The Lancet Commission defined a cheap basic package of drugs, equipment and staff for palliative care. Countries expanding health coverage should include it as a guaranteed benefit.

Metastatic prostate cancer now has six classes of treatment that work, and no trial has ever compared the orders they can be given in. Every trial adds a drug to the front; none asks what should follow it, so the sequence a man receives is decided by habit and by what was licensed first.

Fund proper trials of the methods used to get new evidence into practice (training, reminders, feedback, incentives), measured by whether patients actually receive the better treatment.

Spread causes around nine in ten cancer deaths but receives a small slice of research funding. A funding floor would change what gets studied.

Before spending millions to turn a lab finding into a drug, spend a little to have an independent lab check it is real. Funders would reserve a small slice of money for exactly this.

Failed projects are not published because nobody has the time. Paying for a few months of writing would recover years of otherwise lost work.

Hospitals often lack the staff to switch patients to cheaper equivalent drugs. Private investors could fund the switching teams and be repaid by the health system from the money saved.

Large phase 3 trials often continue for years after interim data show the drug is unlikely to work. Pre-registering futility boundaries at 30 to 50 percent of the information, judged by independent committees and reported publicly, would stop them earlier, sparing patients and freeing money for better ideas.

Give a small number of scientists a decade of guaranteed funding to work on a single hard problem such as dormant cancer cells, with no pressure to publish quickly.

A fifth of patients with solid tumours develop brain metastases and are usually excluded from trials. This would fund a programme that studies and treats them as a disease in their own right.