Incentives reward me-too drugs and marginal gains

Offer a large cash prize to whoever proves, in a rigorous trial, that a cheap existing drug helps people with cancer live longer. Prizes pull effort towards neglected problems.

Governments and foundations would pool a prize of about a billion dollars into an escrowed fund, paid only when a treatment is shown in a well-controlled registration cohort to keep most patients with a currently incurable metastatic cancer, such as pancreatic adenocarcinoma or glioblastoma, disease-free for five years. The winner keeps its patent but accepts a price ceiling.

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.

Investors will not back a single university drug because most fail. A fund that finances fifty of them at once in exchange for a small slice of each one's future royalties spreads the risk enough to attract capital.

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.

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.

Build a drug company that does not need profits, modelled on the ones that developed new tuberculosis and sleeping-sickness drugs, to take on rare, paediatric and undruggable cancers.

Rank hospitals and companies each year on how well their trial participants match the people with the disease in their area, and use the ranking when deciding who gets public research money and trial contracts.

Cheap old drugs such as aspirin, statins, metformin and beta-blockers show hints of cancer benefit but no company will pay for the trials. Create a public fund and a way to update their labels.

No company will pay to find out whether six months of its drug works as well as twelve. A dedicated public fund would pay for those trials, which save patients side effects and health systems money.

Create a way for a charity or university to get a cheap old drug officially approved for a new cancer use, with a few years of protection on that use so trial costs can be recovered without high prices.

Payers would promise in advance to buy a set number of doses at a set price for any drug that meets a defined bar in a rare or childhood cancer, so companies know the market exists before they invest.

Once a class of antibody such as PD-1 blockers is proven, later copies could be approved on smaller trials showing equivalence, forcing price competition and freeing patients and money for genuinely new drugs.

Rate every cancer breakthrough story and press release for spin, using set criteria, and publish the scores so journalists, institutions and readers can see who overstates.

Pay hospitals a single amount for a whole course of cancer treatment, with extra for following the evidence, rather than paying per visit and per drug, which rewards fragmentation.

Oncology societies already grade how much benefit each new drug gives. Payers should tie the maximum price they pay to that grade.

Drugs given accelerated or conditional approval on surrogate endpoints have often stayed on the market for years after the confirmatory trial stalled or failed. The approval would lapse automatically if the sponsor missed agreed enrolment milestones or the readout date, unless an independent panel granted a documented extension.

Scientists are promoted for first-time discoveries and journal prestige, not for replicating others' work or sharing data. A structured section in tenure and promotion dossiers for replications conducted, data and code shared, and registered reports, weighted explicitly in decisions, would change what scientists spend their time on.

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.

Children wait years for drugs because adult trials come first, even when the target belongs to a childhood cancer. Some drugs should start with children.

Taxpayers fund much of the science behind new cancer drugs but never learn what they cost to develop. Disclosure should be a condition of public payment.

Companies often delay the childhood cancer studies they are required to do. A slice of the adult drug's revenue would be held back until the paediatric trial is completed.

Screening finds cancers that would never have caused harm, but programmes only report cancers found. Publishing the estimated overdiagnosis rate alongside would make the trade-off visible.

If a practice's requests are approved almost every time, asking again wastes everyone's money; gold-card rules give such practices automatic approval and audit them instead.

Companies lose money when they prove a shorter course works, so they never test it. Give them a modest reward, such as extra months of exclusivity, when they do.

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.

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.

Investors avoid genuinely new cancer drugs because most fail in mid-stage trials. A public insurance scheme would repay part of the loss when a first-in-class drug fails honestly, making the bet worth taking.

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.

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.

Pay more for drugs that clearly help people live longer or better, and less for those that barely move the needle, using a public benefit scale doctors already use.

When a public company announces a trial failure, it should be required to give the actual numbers, as it must for a success.

Chemotherapy in the last two weeks of life rarely helps and costs a great deal; patients who have an early conversation about what matters to them choose it less often and live at least as long.

Trials show older women with the lowest-risk breast cancers gain almost nothing from radiotherapy after lumpectomy. Yet most still get it. Track and reward omission.

Pay a fixed prize, of tens of millions, to the first team to show that a completely new way of attacking cancer works in patients, so that the riskiest early bets are rewarded even before a product exists.

Several drugs are approved for the same cancer, but nobody tests which order works best because no company benefits from the answer. Public multi-arm trials could settle these questions efficiently.

Regulators should refuse to approve a two-drug combination unless there is evidence that both drugs are doing something, so patients are not exposed to useless extra toxicity and cost.

Instead of paying hundreds of thousands up front for a CAR-T or gene therapy, the health system would pay in yearly instalments that stop if the cancer comes back, so companies are paid for cures, not attempts.

Hospitals in the 340B programme buy cancer drugs at steep discounts but usually bill patients and insurers the full price; requiring the discount to reach low-income patients would turn a hospital subsidy into patient relief.

A drug that adds years of life would earn extra years of market protection; one that adds a few weeks would earn none. Extensions would be lost if the promised benefit is not confirmed.

Fund trials of old, cheap drugs with anti-cancer signals without seeking patents, and have generic makers produce them, so cost, not profit, decides whether patients get them.

Medicare pays clinics the drug's average sales price plus 6%, so a dearer drug earns the clinic more; replacing the percentage with a flat handling fee removes the incentive to pick the expensive option.

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.

One week of breast radiotherapy in five doses works as well as three weeks in fifteen, but clinics paid per dose lose money by switching; paying one price per course removes the penalty.

Health systems would pay for AI tools that have shown in trials that they help patients, and pay nothing for tools that have not, giving makers a reason to run the trials.

Leftover-cancer blood tests are being sold faster than evidence that acting on them helps. Paying for them only when the result is recorded would generate the missing evidence.

A large trial showed a structured exercise programme improved survival after bowel cancer. Almost no health system pays for it, so almost no patient gets it.

Health systems earn from treating cancer, not preventing it. Paying them for lower cancer incidence and earlier stage in their population would flip the incentive.

Trial sites are paid per patient recruited, so nobody is paid to finish the study or report the answer. Shift part of the payment to completion and publication within a year.

Discussing and enrolling a patient in a trial takes an oncologist far longer than prescribing the usual treatment, and they are not paid for it. Paying for that time would remove a quiet disincentive.

Hospitals are paid for each radiotherapy session, so a proven five-session course earns less than an unproven twenty-five-session one. Paying per course removes the reason to give more treatment than needed.

The same chemotherapy infusion costs payers and patients more in a hospital outpatient department than in a doctor's office; paying one rate would stop hospitals buying clinics to charge the higher price.

For very expensive one-time treatments such as CAR-T, pay in instalments over years and stop paying if the cancer comes back, so price tracks the cure actually delivered.

Health insurers and national health systems have every reason to find out whether half the dose or half the duration of a costly drug works as well. They would fund those trials directly and keep the savings.

Even when a trial proves a cheap old drug helps, insurers may refuse to pay because it is not licensed for cancer. A standing promise to pay would remove that fear.

A drug that adds a year of life in one cancer and six weeks in another sells at the same price for both; indication-specific prices would pay for the benefit actually delivered.

Nobody can patent a better way of operating or a shorter radiotherapy schedule, so nobody is rewarded for proving one. Prizes for technique improvements shown to work in trials would fill that gap.

Universities and cancer centres would change how they promote scientists, giving credit for finishing trials, sharing data, replicating others' work and publishing failures, not just for papers in famous journals.

A public investment fund would match private money in the riskiest early trials of truly new cancer drugs, taking a small share of future royalties so that taxpayers gain when the bets pay off.

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.

Some expensive approved cancer drugs probably work as well at lower doses, as reduced-dose abiraterone with food and extended-interval checkpoint inhibitors suggest. Companies will not test this, so payers should fund randomised non-inferiority trials prioritised by spend and pharmacology, and use the results in reimbursement.

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.

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.

Set the price of a new cancer drug provisionally, then adjust it up or down after three years depending on how well patients actually did.

Once two drugs of a kind exist, a third should have to prove itself against the best of them, not against an outdated comparison, so patients and payers learn which is actually better.

The fifth PD-1 antibody that is no better than the first should not get the same market protection as the first. Exclusivity would shrink for copies that add nothing.

Investors would fund vaccination and screening campaigns up front and be repaid by health systems only if the campaigns hit verified targets, turning future savings into money for prevention now.

To get an early approval, a company would set aside the money for the follow-up trial up front, so the trial cannot be quietly abandoned.

Giving men with castration-resistant prostate cancer large doses of the hormone the treatment has spent years removing makes a third of them respond, and makes half of them respond again to the drug that had stopped working. It has never been taken to a definitive trial, partly because the endpoint that shows the benefit is not the one trials usually use.

Nobody funds trials of old drugs because competitors can sell the result for free. A short exclusive period for the new use, like the one given for children's studies, would change that.

Oncology has two respected scales that grade how much a drug helps in each indication; payers could set low copays for high-grade uses and require a conversation for low-grade ones instead of blanket prior authorisation.

Reward companies that deliver a genuinely new kind of cancer drug with a sellable voucher for faster review of another product, but only if they agree to fair pricing and global access.

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.