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Surgery and radiotherapy cure more people than drugs do, but attract a fraction of the research investment.
Surgery remains the principal curative treatment for most solid tumours, and radiotherapy is indicated in roughly half of all patients with cancer and contributes to a large share of cures, yet both attract a small fraction of research funding and almost no industry investment because techniques cannot be patented in the way molecules can. Trials in surgery and radiotherapy are academic, small, slow to recruit and hard to blind, so innovations spread by training lineage and habit rather than evidence, and important questions (extent of resection, de-escalation of radiotherapy dose, hypofractionation, omission of surgery after complete response) wait decades for answers. When trials are done they change practice dramatically: MSLT-II ended routine completion lymphadenectomy in melanoma, LACC reversed minimally invasive surgery for cervical cancer, and hypofractionation trials halved radiotherapy courses in breast and prostate cancer. Dedicated funding streams, trial-quality assurance networks and device-industry partnerships are the routes to more of this.
Record cancer operations (with consent), link each video to the pathology report and the patient's recovery, and open the collection to researchers to learn what surgical technique actually works.
Ultra-fast radiotherapy may spare healthy tissue while still killing tumours, but every centre is testing it differently. A coordinated programme would agree the measurements and run the trials that settle whether it works.
For some cancers, drugs and radiotherapy can now cure without removing the organ, sparing patients a stoma, a lost voice or a removed bladder. A dedicated programme would run the trials to prove where this is safe.
Radiotherapy machines record exactly how much dose every organ received, but the data are thrown away. Collect them and link to toxicities and cures to learn the safest, most effective doses.
Radiotherapy may make immunotherapy work better, but the trials to test this are scattered and often small. One shared platform, run by radiotherapy groups with drugs supplied by several companies, would settle it faster.
Surgery cures more cancer than any drug, yet most operations have never been compared in a proper trial. A standing network of hospitals, with core funding, would run those trials continuously.
Tools that show surgeons where the tumour ends during the operation could cut the number of patients who need a second operation, but none has been properly tested at scale. A network would run those trials and pay on results.
Every attempt to drop radiotherapy from early Hodgkin lymphoma on the strength of a clear scan has cost people their remission. Changing the chemotherapy as well is the next attempt.
Radiotherapy after gallbladder cancer surgery rests on one 79-patient trial with no comparison arm and a US insurance database. People whose surgery left cancer at the edge or in the nodes are the ones it might help, and they have never been randomised.
New ways of giving radiotherapy are adopted without the staged testing that drugs go through, and are then hard to evaluate. A defined pathway with fee waivers and clear evidence steps would bring rigour without blocking progress.
Radiotherapy is given to half of all cancer patients but few new drugs are tested alongside it. A permanent trial platform would test drug-plus-radiation pairs systematically.
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.
New surgical tools, imaging probes and radiotherapy hardware invented in universities rarely attract investors. A dedicated fund would pay for prototyping, safety testing and first-in-human studies.
Muscle-invading gallbladder tumours on the free side of the organ recur in the liver far less often than those against it. Two meta-analyses found the liver resection helped only the liver-side group, so a randomised trial could test dropping it for the free side.
Surgeons' skill affects whether cancer comes back, but nobody measures it. Recording operations and rating them, increasingly with AI, then linking ratings to outcomes, would make surgical quality visible and improvable.
Radiation therapists, the staff who deliver daily treatment, can be trained to outline normal organs on scans and to review patients during treatment, work that oncologists now do.
Hospitals buy multi-million-dollar surgical robots and AI tools with little proof they help patients. An independent body would run the comparative trials, and payers would only pay premiums for what is shown to work.
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.
Giving chemotherapy before the operation is standard when the tumour is borderline operable, but for tumours that can be removed straight away two trials have failed to show it beats operating first. Two more, one Dutch and one American, are directly comparing chemotherapy before and after surgery with chemotherapy after alone; the proposal is to wait for them and to pool them.
Ultra-fast FLASH radiotherapy and proton beams may spare healthy tissue dramatically, but the machines cost tens of millions. Engineer versions that any hospital can afford.
Radiotherapy trials need physicists to check every plan and central review of every target drawn, which nobody pays for. Fund that infrastructure permanently so trials are faster and results are trustworthy.
Radiotherapy machines that adapt to the tumour each day cost far more than standard ones and their benefit is unproven. Payers would fund them only within registries and trials that measure whether they help.
Focused ultrasound, histotripsy, heat and electric-field ablation can destroy tumours without an incision, but each maker runs its own small study. Publicly-funded trials would compare them fairly against surgery.
Bowel cancer that has seeded the lining of the abdomen responds badly to drugs but well to a complete operation, and the heated chemotherapy that everyone added turned out to do nothing. What decides the outcome is whether the disease is found while it is still limited and whether the patient reaches a centre that can remove all of it.
Almost no surgeons or radiation oncologists have time or funding to do research. Dedicated training awards with protected time would build the workforce that surgical and radiotherapy trials need.
When a geriatrician co-manages patients over 75 around a cancer operation, as in the POSH programme at Duke and POPS in the UK, complications, delirium, length of stay and readmissions fall. Preoperative optimisation and postoperative geriatric review should be a standard part of surgical oncology pathways for this age group.
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.
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.
New operations and surgical devices spread by enthusiasm before evidence, as robotic prostatectomy, minimally invasive radical hysterectomy and HIPEC did. Every new cancer surgical technique would follow the IDEAL framework, with a prospective registry from first use, defined triggers for a randomised comparison, and payment conditional on registry participation until assessment is complete.
Focused ultrasound can break a tumour apart without heat or cuts, leaving debris the immune system can learn from. Doing that to one tumour may help treat the rest.
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.
A few weeks of exercise, nutrition and mental preparation before a big operation helps older patients recover faster and with fewer complications. It costs little and should be routine.
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.
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.
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.
Low-risk patients often receive operations and radiotherapy they may not need, for example sentinel node biopsy in older women with favourable breast cancer or radiotherapy after breast-conserving surgery in genomically low-risk disease. Because no company will sponsor trials of leaving treatment out, health systems should fund them and keep the savings.
Radiation can alert the immune system through the cGAS-STING pathway, but single doses above roughly 12 to 18 Gy switch on the enzyme TREX1, which destroys the alarm signal. Choosing fractionated schedules around 8 Gy times three for immune priming may add benefit at no extra cost.
Proton therapy costs far more than standard radiotherapy and, for most adult cancers, nobody knows whether it is better. Payers would cover it only inside trials or registries that answer that question, across every centre at once.
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.
Where you have your cancer operation strongly affects whether you survive it. Publishing each hospital's adjusted results would push complex surgery towards the centres that do it well.
Prostate MRI is good at telling you whether a man has a serious cancer and poor at telling you where all of it is. It missed at least one significant tumour in a third of men in the study that checked it against the whole removed prostate. Services that treat part of the gland, or follow men on imaging alone, are relying on the number they do not measure.
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.
Half of rectal cancer patients given all their chemotherapy and radiotherapy first can keep their rectum. Nobody has ever randomised that against having the operation, so the trade-off between avoiding a stoma and the risk of the cancer regrowing is still guesswork.
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.
Pumping drugs slowly through fine tubes into a brain tumour can bypass the barrier, but the fluid often leaks away. Robotic placement and live scans would show where it actually goes.
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.
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.
Guidelines send everyone whose chance-found gallbladder cancer has just reached the muscle layer back for liver and lymph node surgery, yet the largest international series found 95 in 100 alive without the disease at five years whether or not they had it. A prospective study could spare thousands of operations, or confirm they are needed.
Protons cost more than shaped X-ray beams. They are worth it when the extra punch where the beam stops, and the missing exit dose, widen the gap between killing the tumour and harming late-reacting tissue: an alpha/beta and RBE question, not a machine question.
Drawing targets and planning radiotherapy takes hours of scarce expert time. Properly tested AI could do much of it, letting the same staff treat far more patients, if regulators and payers set clear rules for proving and paying for it.
For mismatch repair-deficient rectal cancer, six months of a single antibody now replaces chemotherapy, radiotherapy and an operation, and the same appears to be true for early-stage mismatch repair-deficient cancers of other organs.
Patients with high-risk bladder cancer confined to the lining whose disease has not responded to BCG now have a bladder-sparing option that clears the cancer in most cases, delivered through a simple outpatient procedure. It may allow many to avoid or defer cystectomy, a life-changing operation. Whether responses translate into avoided progression and cystectomy over the long term, and how it compares with cystectomy on survival, remain to be shown.
Patients with limited-stage small-cell lung cancer who complete chemoradiotherapy without progression should now be offered up to two years of durvalumab consolidation, which extends life by almost two years on average. This is the first survival improvement for limited-stage disease since twice-daily radiotherapy and prophylactic cranial irradiation, and small-cell lung cancer is no longer a disease where immunotherapy gives only marginal gains.
Patients with melanoma that has spread to palpable lymph nodes should now be offered immunotherapy before rather than only after surgery: two cycles of low-dose ipilimumab with nivolumab, then surgery, with the pathology result deciding whether any more treatment is needed. Most patients respond well and are spared a year of adjuvant therapy. Serious side effects are more common than with nivolumab alone, mostly endocrine, and the approach requires close coordination between oncologists, surgeons and pathologists.
For colon cancer that is mismatch-repair deficient (about 10-15% of colon cancers, more in older patients), a single short course of immunotherapy before surgery is now a reasonable standard and is far more effective than chemotherapy, which has little effect in this subtype. It requires testing every colon cancer for mismatch repair at diagnosis, before surgery. Whether some patients can safely skip surgery, as in dMMR rectal cancer, is the next question.
The strongest signal that neoadjuvant immunotherapy makes stage III lung cancer operable as well as more often curable. Twenty-four percentage points more patients reaching surgery is a result that only a neoadjuvant design can produce.
A UK-led trial that moved part of colon cancer chemotherapy in front of the operation, and showed that tumour regression grade after six weeks predicts recurrence, which is the basis for using the response itself to choose what follows.
Cercek's dostarlimab study is the clearest demonstration that immunotherapy can replace surgery in a solid tumour: patients with dMMR rectal cancer can keep their rectum and avoid the permanent effects of pelvic radiotherapy and surgery. Non-operative management after PD-1 blockade is now in guidelines for this group, and MMR testing before treatment of rectal cancer is essential. The approach applies only to the 5-10% of rectal cancers that are dMMR.
Shares Nomogram for predicting the benefit of adjuvant chemoradiotherapy for resected gallbladder cancer, Improved survival with preoperative radiotherapy in resectable rectal cancer (Swedish Rectal Cancer Trial), Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016), SWOG S0809: A Phase II Intergroup Trial of Adjuvant Capecitabine and Gemcitabine Followed by Radiotherapy and Concurrent Capecitabine in Extrahepatic Cholangiocarcinoma and Gallbladder Carcinoma.
Shares Modernised cobalt-60 machines as a deliberate bridge where linacs cannot be kept running, Goh Cheng Liang, Single-fraction radiotherapy as the default for painful bone metastases, Low-cost cobalt-60 brachytherapy for cervical cancer in every regional centre.
Shares Nomogram for predicting the benefit of adjuvant chemoradiotherapy for resected gallbladder cancer, Bernard Fisher, Improved survival with preoperative radiotherapy in resectable rectal cancer (Swedish Rectal Cancer Trial), Preoperative chemotherapy for operable colon cancer: mature results of an international randomized controlled trial (FOxTROT).
Shares Nomogram for predicting the benefit of adjuvant chemoradiotherapy for resected gallbladder cancer, Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016), SWOG S0809: A Phase II Intergroup Trial of Adjuvant Capecitabine and Gemcitabine Followed by Radiotherapy and Concurrent Capecitabine in Extrahepatic Cholangiocarcinoma and Gallbladder Carcinoma, Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results.
Shares The mesorectum in rectal cancer surgery: the clue to pelvic recurrence?, Improved survival with preoperative radiotherapy in resectable rectal cancer (Swedish Rectal Cancer Trial), Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016), Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer (Dutch TME trial).
Shares A national repository of radiotherapy dose plans linked to outcomes, Compact FLASH and proton systems at the price of a conventional linac, SunRISe-1: TAR-200, a gemcitabine-releasing device placed in the bladder, for BCG-unresponsive non-muscle-invasive bladder cancer, Bernard Fisher.
Shares Organ preservation as the default after complete response in oesophageal cancer, Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results, SANO, Nonoperative management of mismatch repair-deficient tumors.
Shares Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer, Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy versus cytoreductive surgery alone for colorectal peritoneal metastases (PRODIGE 7), Mandatory staged registries for new surgical techniques before wide adoption, European Society of Surgical Oncology.