Most of the world has almost no cancer care

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.

A low dose of an old, inexpensive tablet improved appetite and weight in a randomised trial of people with advanced cancer. It could be used almost everywhere tomorrow.

A handful of ageing research reactors make most cancer isotopes. Coordinating their maintenance and funding reserve capacity would prevent the shortages that stop treatments.

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.

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.

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.

Companies could choose to sell a new cancer drug at cost worldwide and instead be paid from a pooled fund according to how much health it actually delivers.

Small European countries have started negotiating cancer drug prices together. A bloc of large middle-income countries would have far more bargaining power.

Hospitals in poorer countries often run out of basic, cheap chemotherapy for weeks. A shared live map of stock levels would let buyers and donors act before a child's treatment is interrupted.

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.

Cisplatin and carboplatin cost a few dollars a dose yet ran short across the US in 2023 because too few makers found them worth producing; a non-profit maker with long-term hospital contracts would keep them on the shelf.

Children with cancer, and their families, need symptom relief and support from diagnosis, not only at the end. Every children's cancer unit should have a palliative team, and most in poorer countries have none.

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.

Cancer patients have had treatments delayed because basic chemotherapy drugs ran out. Keeping a national stockpile, like for flu antivirals, would prevent this.

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.

Let validated AI make the first read on routine, high-volume samples like cervical smears and standard breast biopsy stains, so scarce pathologists spend their time on the difficult cases.

Training a specialist doctor takes ten years or more. Mid-level clinicians can be trained in eighteen months to run protocol-based cancer care under supervision, and there are far more of them.

Immunotherapy patents start expiring around 2028. Guaranteeing in advance to buy cheap copies for poorer countries would make sure manufacturers build the capacity.

Design a radiotherapy machine from scratch for hospitals with patchy electricity, heat and few engineers, and publish the design so several companies can build it cheaply.

Dozens of countries have no radiotherapy machine at all. Combine long-term finance with a machine designed to be cheap, robust and maintainable where power and engineers are scarce.

Nasopharyngeal cancer is common in southern China and is caused by a virus. A blood test for viral DNA finds it early, and a large study showed better survival. Scale it up.

Travel and time off work are among the biggest costs families face; if consultations happen by video, blood tests locally and oral drugs by mail, most routine visits need no journey at all.

The lutetium used in approved prostate and neuroendocrine cancer treatments is made from an enriched metal that comes mostly from Russia. Making it elsewhere would secure supply.

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.

Governments and philanthropies would pay a company a one-off lump sum, set by auction to reflect the drug's social value, for the patent on a cancer drug with a large benefit in a common cancer, then let generic makers supply it worldwide at competitive prices. A pilot fund would buy out one or two oncology patents.

Treatment abandonment is the leading cause of treatment failure for childhood cancer in much of the low- and middle-income world, driven by bus fares, lost income and the cost of food and lodging. Conditional cash, transport vouchers and family accommodation have cut abandonment sharply in Central America, East Africa and India, and should be funded in every curative protocol.

People who carry the typhoid bacterium in their gallbladder long term have about four times the usual risk of gallbladder cancer. Two meta-analyses suggest offering them gallbladder removal or regular scans; no programme has tried it.

When a hospital's real limit is the number of chemotherapy chairs and nurses, guidelines should favour treatments given by mouth or in fewer, shorter visits, if they work about as well.

Black women in the United States have about twice the odds of a triple-negative diagnosis and, in the UK POSH cohort, worse survival than White women despite equal chemotherapy use. The pivotal trials enrolled few of them. Enrolment targets tied to incidence, reported by ethnicity in every primary paper, would make the evidence match the disease.

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.

Mouth cancer is common where tobacco is chewed and is visible to the naked eye. Health workers with a phone camera and AI could find it early in villages.

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.

Thousands of oncologists trained in poorer countries now work abroad. A structured programme could let them join weekly video case conferences for hospitals back home, improving decisions at almost no cost.

The rules that decide who gets a lung scan count cigarettes. A risk model that also uses age, sex, family history, deprivation and lung disease would find more cancers in the same number of scans, and would stop excluding people who smoke less but are more likely to get the disease.

The nerves at the top of the nose lead directly into the brain, bypassing the barrier. Nasal delivery of drugs, and even immune cells, has worked in animals.

Many countries have one oncologist for millions of people. Train nurses and general doctors to deliver protocolised cancer care with software checks and remote specialist oversight.

About one in eight cancers is caused by an infection we can vaccinate against, cure or eradicate. A concerted global programme could make those cancers rare within a generation.

Outside US Medicare and Medicaid, joining a trial can leave the patient or hospital paying for the ordinary care that goes with it, and billing uncertainty blocks participation in middle-income countries. Requiring every insurer and public system to cover routine care costs removes a hidden barrier.

Most oncology guidelines exist only in English, and national adaptations lag by years and often diverge. Machine translation checked by a clinician-verifier per language could publish each recommendation update in 20 languages within 30 days, side by side with the source and with local adaptations flagged explicitly.

Africa's new continental medicines agency could assess cancer drugs once for 55 countries. It needs oncology reviewers and a reliance rule to do it.

Wikipedia is the most-read medical reference on Earth. Pay expert editors to keep its cancer pages accurate, current and available in the languages most patients speak.

A drug that improves appetite and lean weight in cancer wasting is approved in Japan but almost nowhere else. Reviewing the existing evidence could widen access quickly.

Under-the-skin versions of atezolizumab, nivolumab and pembrolizumab take minutes rather than an hour and need no infusion chair, so they can be given by a nurse near home, cutting facility fees and travel.

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.

Most children with cancer in rich countries are cured; most in poor countries are not, often because cheap drugs are missing. A global platform now ships quality drugs free; scaling it to 50 countries would be one of the highest-value cancer interventions available.

Most people in poorer countries die at home without any professional support. A simple kit of medicines and supplies plus a few hours of training for a family member could make dying far less painful.

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.

Some new medicines reprogramme immune cells inside the body with an injection, skipping the factory entirely. Test whether that makes CAR-T affordable and available in ordinary hospitals.

Instead of making cell therapy from each patient's own cells in a factory, inject a particle that reprograms immune cells inside the body, made in bulk, so a dose costs thousands rather than hundreds of thousands.

A drug approved in the US may take five years to reach a patient in Poland or never reach Nigeria. A live public tracker would show exactly where and why it is stuck.

Cancer treatment guidance changes constantly and takes years to reach many clinics. Make guidelines live documents that software can read, updated as evidence arrives and adapted to what each country can afford.

Uganda makes liquid morphine from powder in a simple facility and lets trained nurses prescribe it, giving pain relief to patients that no doctor will ever reach. Other countries could copy this within a year.

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.

A cheap, old antipsychotic at a low dose is one of the best anti-sickness drugs for chemotherapy. Make sure every cancer unit in the world uses it.

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.

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.

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.

Vans equipped with ultrasound, biopsy kits, cervical screening and a link to a distant pathologist could bring a cancer diagnosis, and for cervical pre-cancer immediate treatment, to villages far from any hospital.

In places where sophisticated machines break down, a modern version of the older cobalt radiotherapy unit, upgraded with image guidance, could treat more people reliably while infrastructure catches up.

Instead of one overwhelmed national cancer hospital, organise care in tiers: district hospitals diagnose and give simple treatment, regional centres give chemotherapy and surgery, and the hub handles radiotherapy and complex cases.

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.

The engineered virus that delivers the CAR gene costs tens of thousands of dollars per patient and is controlled by a few suppliers. A non-profit supplier with open licences would cut that cost sharply.

Trained nurses following strict written protocols can safely run chemotherapy clinics for common cancers, with an oncologist available by video for decisions and problems.

A phone app that works without internet and guides a general doctor or nurse through diagnosing and treating common cancers with the drugs actually available locally.

Medical physicists, who keep radiotherapy machines accurate and safe, are in even shorter supply than oncologists in under-resourced systems. Routine linac quality assurance is now largely automated and log-file based, so one physicist could review it remotely while trained radiation therapists take the measurements, covering three to five machines once regulators define the supervision standard.

Companies and charities give or discount cancer drugs in poorer countries, but nobody records whether the patients did well. Make a simple outcome record part of every programme.

Guidelines paid for with public or charitable money would be published under an open licence so any hospital system, app or country can build them in without permission or fees.

A registry-in-a-box would be a free, ready-to-run cancer registry system, working on phones and without constant internet, so any hospital anywhere can start counting and following its cancer patients.

Train and pay people who have been through cancer to guide newly diagnosed patients through the system, especially where oncologists and nurses are scarce.

Palliative care given early alongside cancer treatment improves quality of life and sometimes survival, and most of the world has no access to it or to morphine. Make both universal.

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.

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.

Small countries pay more for the same generic chemotherapy because they buy alone; the PAHO Strategic Fund and the WHO essential medicines list show that buying together brings prices down and keeps supply steady.

Countries buying cancer drugs alone pay more and face shortages. Buying together, as they already do for childhood cancer drugs and vaccines, cuts prices and secures supply.

Buy essential cancer drugs for many countries at once and license newer ones to generic makers, as was done for HIV, so prices fall to what those health systems can pay.

Taking 250 mg of abiraterone with a low-fat breakfast gives the same PSA response and testosterone suppression as the standard 1,000 mg fasting, because food increases absorption several-fold, so a quarter of the drug treats each man. The label still says fasting and no company promotes the food-effect dose, so adoption is patchy.

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.

The WHO set three simple goals for breast cancer: most cancers found early, diagnosis within 60 days, and most patients finishing treatment. Every country should publish how it is doing on each, every year.

Cheap, essential chemotherapy drugs such as cisplatin keep running short because there is little profit in making them. A publicly-backed non-profit manufacturer would guarantee supply at a fair price.

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.

Every targeted result on this roadmap depends on a test happening fast enough to act on. In England nobody publishes what share of lung cancers are tested, how long the test takes, or, in Wales and Northern Ireland, how long the lung pathway takes at all.

Cytisine costs a few dollars per course and works about as well as varenicline, but is unavailable in most countries. Global approval and procurement would make quitting affordable.

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.

Half of cancer patients need radiotherapy and most of the world cannot get it. Commit to low-cost machines, automated planning and trained staff so that access is universal by 2040.

Adult T-cell leukaemia has had one randomised trial, in 1998. Most T-cell lymphoma treatment rests on single-arm studies, and the diseases concentrated outside Europe and North America have the least evidence of all.

Surgeons often cannot see where a tumour ends. Fluorescent dyes and AI-read imaging in the operating theatre can show them, cutting repeat operations. Make this routine everywhere.

When a trusted regulator approves a cancer drug for a rare genetic target, other countries should recognise that approval within months instead of repeating years of review.

Radioactive cancer drugs decay while they travel and get stuck at borders. Regional production and simpler transport rules would get more doses to patients on time.

Rather than sending a handful of trainees to Europe or America, build a few large training centres in Africa and South Asia that train the whole team together, with local case mix and local costs.

When Black and white men in the United States are given the same treatment, the gap in dying of prostate cancer largely closes. The gap in dying of everything else does not. Cancer services measure the first and not the second, which means the surviving disparity is invisible to the people best placed to act on it.

Radiation oncologists and physicists from poorer countries who train abroad commonly emigrate, and money alone does not keep them. A package combining a return-of-service bond, salary top-ups, a guarantee of working equipment, academic links and a predictable career path, co-funded by government and donors, should be trialled with five-year retention measured.

In parts of Chile and northern India gallbladder cancer is common enough that a cheap ultrasound programme aimed at the highest-risk people might catch it while surgery can still cure it. Nobody has run the trial.

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.

Where women cannot return for results, test for HPV and treat any precancer the same day with a battery-powered heat probe. This is the fastest route to WHO's cervical elimination target.

Randomised trials and meta-analyses show a single 8 Gy radiotherapy session relieves pain from uncomplicated bone metastases as well as ten sessions, with a higher retreatment rate, yet habit and per-fraction payment keep most patients on the longer course. Making one session the default, with an opt-out justification and payment neutrality, would spare patients trips and free machines.

In much of Africa and South Asia there is about one pathologist per million people, so the pathologist, not the tissue sample, is the diagnostic bottleneck. A slide scanner in each district lab, routing images to a pooled roster of pathologists including diaspora volunteers, could give a diagnosis in days instead of months; the gap is scale and financing.

Cancer units in poorer countries lose treatment days, spoil drugs and damage machines during power cuts. Solar panels with batteries sized for the cancer unit would remove that failure point.

Surgery cures more cancers than any other treatment, but most district hospitals refer everything to a distant centre. Train and mentor general surgeons to do common cancer operations well, with specialists checking results.

Instead of paying per dose, a country would pay a fixed annual fee and treat every eligible patient with immunotherapy. This has worked for hepatitis C drugs and antibiotics.

One dose of HPV vaccine protects as well as two or three. Halving the doses frees supply to vaccinate far more girls, boys and young adults.

A randomised trial at Tata Memorial added nivolumab at 20 mg every three weeks, about one-twelfth of the standard dose, to cheap metronomic chemotherapy for head and neck cancer patients who could not afford full-dose immunotherapy, and they lived longer. Checkpoint inhibitors saturate their target far below approved doses, so publicly funded trials should test low doses in common cancers.

Lymphoma is among the most curable common cancers where the drugs exist. Rituximab is thirty years old and still out of reach for many of the people who need it.

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.

Hepatitis B causes most liver cancer worldwide, and generic tenofovir suppresses it for under 30 dollars a year. Treating everyone infected, not just those with liver damage, as WHO's 2024 guidelines allow, would cut liver cancer incidence because viral load predicts it and antivirals reduce it in cirrhotics.

The only randomised trial of screening colonoscopy cut bowel cancer by 18 percent because only 42 percent of the people invited turned up. A test that is 20 percent more sensitive but is taken by the same people buys far less than an invitation that 20 percent more people accept.

Poorer patients with lung cancer are less likely to be offered surgery or chemotherapy, at the same stage, in systems that are free at the point of use. That is a fixable problem in how care is delivered, not a fact about the disease.

When morphine is unavailable, patients get nothing. Some cheap alternatives, such as methadone or tramadol, may work for cancer pain but have not been properly tested in these settings.

Every positive stool test in England, from the screening programme and from the symptomatic pathway, ends in a colonoscopy. The thresholds have been lowered faster than the capacity to act on them, and who performs the test decides whether it prevents anything.

When universities license cancer discoveries to companies, the contract would reward companies that price fairly and sell in poor countries, and penalise those that do not, using the royalty rate as the lever.

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.

India's 2012 compulsory licence on sorafenib cut its price by about 97% and its 2019 cap on trade margins lowered the shelf price of 42 cancer drugs; voluntary licences through a patent pool would achieve the same without a fight.

In Kerala, trained community volunteers, backed by nurses and doctors, provide most home palliative care to the dying. The model reaches more people at lower cost than any clinic-based service and could be copied.

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.