Toxicity and quality of life are undervalued

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.

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.

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.

Children treated for cancer are followed for decades in a study that has changed how they are treated. Adults have nothing similar. Build it.

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.

Instead of one-off small studies, run a standing trial that continuously tests new treatments for side-effects, adding and dropping arms as evidence arrives.

Nerve damage from taxanes and platinum is common, often permanent and has no approved preventive. Test the most promising candidates head to head in one programme.

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.

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.

Some chemotherapy and antibody drugs damage the heart. Checking heart function before and during treatment and starting protective drugs early for those at risk could prevent much of that damage.

Cancer care has more handoffs than most conditions, hospital to home, surgery to chemotherapy, oncology back to the family doctor, and information and medications are lost at each. A standard handoff checklist plus pharmacist medication reconciliation covering oral anticancer drugs, steroids, anticoagulants and opioids at every transition would prevent avoidable adverse drug events cheaply.

A cancer patient with a fever or severe sickness during treatment should be seen quickly by a team that knows chemotherapy, not wait hours in a general emergency room.

A reported prevalence of 0 to 84 per cent for the same late effect is a measurement failure. Core outcome sets are cheap, need no new biology, and would unlock the studies the field has already paid for.

A supportive-care ARPA would be a well-funded, milestone-driven agency that develops drugs for nausea, nerve damage, mouth sores, fatigue and brain fog from cancer treatment, which the market has largely ignored.

Pool the side-effect and quality-of-life data patients report in trials into one open database so regimens can be compared honestly and models can be built.

Most patients take supplements and rarely tell their oncologist. Ask routinely and check automatically for interactions with chemotherapy and targeted drugs.

Women get more severe side effects than men at identical doses of fluorouracil, several kinase inhibitors and immune checkpoint inhibitors in pooled analyses. Trials should pre-specify sex-stratified drug level and toxicity analyses and, where they differ, run sex-specific dose-finding and label accordingly.

TGF-beta is a signal that keeps immune cells out of tumours, but blocking it throughout the body caused bleeding and heart toxicity and sank bintrafusp alfa. Tethering the blocker to tumour stroma with a FAP anchor, a collagen-binding domain or a protease-activated mask could give the benefit without the harm.

The FDA now requires new cancer drugs to prove their dose is the right one rather than the highest tolerated; asking the same question of the twenty best-selling approved drugs could cut doses, side effects and cost at once.

Anthracyclines, HER2 drugs and some newer agents can damage the heart. Monitor with blood tests and scans and start cheap heart-protective drugs early in those at risk.

Drugs that grab T cells and drag them onto tumours work well in blood cancers. The same trick aimed at tumour-eating cells might work where T cells are absent.

Slow weight loss and falling daily activity are the first signs of cancer wasting, and both can be measured at home. An alert could bring help months earlier.

A new antibody blocks the hormone that makes people with cancer lose appetite and weight. Weight regained as muscle, not fat, needs exercise and protein alongside it.

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.

Half of patients take antioxidant vitamins during chemotherapy. One good observational study suggests they raise recurrence by 40%. Patients deserve a definitive answer, and it can be obtained cheaply by adding supplement tracking to trials already running.

Trials report side effects as a table of percentages that hides how long they lasted, how bad they felt and whether people stopped treatment. Tolerability should be measured with defined endpoints and a decision rule, like efficacy.

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.

Patients report symptoms on their phone each week; a set of rules turns severe or worsening symptoms into a dose hold or reduction before the next clinic visit. This could keep people on treatment longer and feeling better.

Antibody-drug conjugates deliver chemotherapy payloads into tumours but cause lung, eye and nerve damage that tracks total exposure, and several were approved without an optimised dose. Randomised comparisons of lower doses, longer intervals and capped cumulative payload could keep the benefit while cutting these harms.

Chemotherapy doses are calculated from height and weight, a formula from the 1950s. Doses based on actual muscle mass may cause fewer severe side-effects.

Trials often require a fresh tumour biopsy just to enter, even when the sample is only for research. Classifying each biopsy as essential or research-only, making the latter optional and allowing blood tests or archived tissue for eligibility markers, would remove a painful hurdle that drives refusals.

Offer the complementary approaches that have evidence (acupuncture for nausea and pain, exercise, mindfulness, yoga) inside the cancer centre, so patients do not seek them, and worse, elsewhere.

Immunotherapy antibodies stay active in the body for weeks, yet are often given every two or three weeks. After a few months, spacing doses out to every two or three months might work as well, with fewer hospital visits and much lower cost.

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.

Everyone of reproductive age about to have treatment that can cause infertility is offered egg, sperm or tissue freezing, paid for, before treatment starts.

Protein-destroying drugs work by hijacking cellular waste-disposal machines. Using a machine that is mostly present in cancer cells would make these drugs safer.

Several treatments now work without chemotherapy, but most are given until the disease comes back. Giving them for a fixed time and stopping is the version patients would choose.

Losing hair is one of the most distressing side-effects of chemotherapy and can often be prevented with a cooling cap. Make it routinely available and paid for.

A short structured check of memory, mobility, nutrition and medicines before treatment cuts serious side effects in older patients without reducing benefit. It should be automatic, not optional.

Two thirds of women treated on the KEYNOTE-522 regimen have no tumour left at surgery and about 92 percent of them are alive without relapse at five years, yet all receive nine more cycles of pembrolizumab. Trials are now testing whether the best responders can stop early, skip the anthracycline, or in lymphocyte-rich stage I tumours skip chemotherapy altogether.

Hospital-at-home programmes deliver intravenous antibiotics, fluids, monitoring and daily nurse and physician visits in the patient's home, with equivalent or better outcomes and lower costs in general medicine. Extending them to low-risk fever after chemotherapy and dehydration, with payer recognition, would keep older cancer patients out of hospital beds, where they are most at risk of harm.

Damage to the lungs, heart or liver is a common reason cancer drugs fail. Connected chips of human tissue may spot this earlier than animal tests.

Use joined-up pharmacy and hospital records to spot when a common everyday medicine makes a cancer drug work worse or cause more harm.

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.

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.

Hospitals publish survival and infection rates but almost never how many of their cancer patients are in uncontrolled pain. Measuring and publishing it would make pain a priority.

Many people report thinking and memory problems after cancer treatment. Measure it properly with short phone-based tests and run trials of treatments.

Blood levels of oral cancer pills vary several-fold between people on the same dose, so some are under-treated and others poisoned. Checking levels and adjusting the dose, as is routine for some antibiotics, could fix both.

Lung cancer spreads to the brain more than any other common cancer, and the newest drugs seem to stop it happening. Almost no trial is designed to prove that, so the claim stays a footnote.

Everything known about the long-term cost of curing lymphoma comes from people treated decades ago with much larger radiation fields. Nobody knows the forty-year risks of what is given today.

People differ several-fold in how they absorb and clear cancer pills. Measure blood levels and adjust each person's dose, as is routine for some antibiotics and transplant drugs.

Manage fevers, dehydration and other treatment side-effects at home with visiting nurses, wearables and video, instead of admitting people to hospital wards.

Doctors record only part of what patients suffer. Make it compulsory that patients report their own side-effects in every trial used to approve a drug, and that those data are published next to the doctor-graded ones.

Every cancer clinic would collect patients' own reports of symptoms and quality of life through a standard questionnaire that feeds straight into the record and into research datasets.

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.

If two drugs extend life equally but one makes patients much sicker, the health system should pay less for the sicker one. Build that into how prices are set.

Oral kinase inhibitors, CDK4/6 inhibitors and hormonal agents interact with proton pump inhibitors, anticoagulants, statins and antiarrhythmics, and are increasingly prescribed to older patients taking all of them. A mandatory oncology pharmacist review at initiation, dose change and refill, with a structured monitoring plan, would catch these interactions systematically.

Mouth ulcers and loss of taste from chemo and radiotherapy stop people eating. Low-level light therapy and structured swallowing and taste rehabilitation can help; make them standard.

Immunotherapy can trigger dangerous attacks on the gut, lungs or heart. Use blood, gut bacteria and genetic markers to spot who is at risk and act early.

Arm swelling after breast cancer surgery is common and lifelong once established, but if caught early with simple measurements and treated with a sleeve, most cases can be prevented from becoming permanent.

Men on active surveillance for prostate cancer have repeat biopsies every year or two, a burden that drives some towards surgery. Triggering biopsy only when MRI, PSA density or new markers change, tested against scheduled biopsy in a 2,000-man non-inferiority trial, could be just as safe with far fewer biopsies.

Cisplatin causes permanent hearing loss. A cheap drug, sodium thiosulfate, protects children; test and roll it out for adults too.

Report how long patients lived well, not only how long they lived. Methods exist (Q-TWiST) but are rarely used.

Cancer drugs are usually tested at the highest dose patients can stand, and that dose sticks for life. Comparing two or more doses head-to-head before the big trial would find doses that work as well with fewer side effects.

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.

Many cancer drugs are approved at the highest dose patients could stand, not the best dose. Run trials that test lower doses on approved drugs and measure how patients feel.

Immunotherapy is often given for two years or until it stops working, but responses can last long after stopping. Trials that randomly assign responders to stop or continue would show whether the extra year is needed.

The first drug against the KRAS protein nearly doubled survival in pancreatic cancer in 2026, but on its own it holds the disease for months, not years. Trials are now testing it in combination with a second RAS drug and with chemotherapy, and earlier in the disease; the open questions are which combination, in which order, and what works when the tumour escapes.

Every staging scan contains a precise measure of muscle mass that nobody looks at. Software could report it automatically and flag patients heading for wasting.

Track how much of each cancer drug patients actually receive and how often they need to reduce it, and use that to change the official dose when the label is too high.

The dose needed to shrink a tumour may be higher than the dose needed to keep it from growing back. Trials that lower the dose once a response is achieved could reduce long-term side effects without losing control.

Alongside how many months a treatment adds, patients should be told how many days it takes from them in clinics, infusions, scans and recovery.

A treatment that adds two months of life but takes up most of those days in hospitals and clinics may not be worth it to an older patient. Trials should report how many days treatment consumes.

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.

People with cancer are far more likely to go bankrupt than people without, and the ones who do have worse survival; a two-question screen at diagnosis plus a financial navigator catches the problem while it can still be fixed.

Cancer treatment often damages sexual function and intimacy, and almost nobody asks. Make it a routine question with a clinic to refer to.

Instead of starting everyone on the full dose and cutting back after side effects, start lower and increase in patients who tolerate it. This keeps more people on treatment and is how blood-pressure drugs are given.

Older cancer patients often take ten or more medicines, some of which no longer help and may interact with cancer treatment. A pharmacist review to stop unnecessary ones, at diagnosis and when goals change, would reduce harm.

A blood test after surgery already lets stage II colon cancer patients skip chemotherapy safely. The same test in stage III would spare far more people, and the unproven half, giving more chemotherapy to those who test positive, has so far changed nothing.

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.

A cheap gene test for DPYD, UGT1A1 and TPMT or NUDT15 before fluoropyrimidines, irinotecan or thiopurines identifies people at risk of severe or fatal toxicity so their dose can be lowered. The EMA has recommended DPD testing since 2020; US uptake remains partial.

For treatments that will not cure, what matters is how long the treatment keeps working without becoming unbearable, and how the person feels. Trials should measure both of those as their main results.

New cancer drugs should have to prove not only that they extend life but how they affect how people feel and function, with that result printed in the label like efficacy.

Give the nurses and pharmacists who take patients' calls a tool that walks them through recognising and managing side effects of modern cancer drugs, including when to escalate.

The wasting that kills many cancer patients has had no effective drug. New antibodies against GDF-15 restored weight in early trials. Combine them with exercise and nutrition and test properly.

Immune side-effects are usually treated with high-dose steroids, which may also switch off the anti-cancer response. Targeted alternatives may control the side-effect and keep the benefit.

Insomnia therapy works well for cancer survivors and is barely offered. A trial that fixes sleep and then follows recurrence would test whether restoring the body clock changes the disease as well as the symptom.

The first lymph node cancer reaches is also where the immune system learns to fight it. Injecting immunotherapy into that node before surgery, instead of removing it blindly, may work better.

A substantial minority of survivors report foggy thinking and memory problems for years after chemotherapy, limiting work and daily life, and no funded service exists for it. Small trials of computerised cognitive training, strategy training and exercise show benefit; a definitive multi-arm trial with a functional endpoint would establish or refute a treatable condition.

Drugs that destroy proteins can hit healthy cells too. Attaching them to an antibody that only docks onto tumour cells would keep them where they are needed.

Extended hormone therapy after breast cancer prevents late recurrence in a minority of women while imposing joint pain, bone loss and sexual side-effects on everyone for a decade. A sensitive residual disease blood test at year five, repeated annually, could show who can safely stop.

If a blood test shows no tumour DNA after months of treatment, a trial could test pausing the drug and restarting only when the DNA reappears, giving patients time off without waiting for scans to show growth.

Cancer survivors are substantially more likely to be unemployed than the general population, though with support they could often work. Vocational rehabilitation covering fatigue management, cognitive strategies, employer liaison and phased return has moderate trial evidence, mostly from Europe, and should be part of cancer care from diagnosis with a named coordinator, as it is for stroke.

Step counts and sleep from a wristband could show whether a cancer treatment is helping or harming daily life. Prove they track survival and quality of life, then use them in real-world studies.

Patients on chemotherapy who report their symptoms weekly through an app, with nurses acting on alerts, live longer and visit emergency rooms less. This should be routine and paid for.

Patients on chemotherapy or immunotherapy answer a short weekly symptom questionnaire on their phone; severe answers alert the nurse the same day. Trials show this prolongs life.

Every patient on the new drug is compared with every patient on the old one: who lived longer, and if equal, who had fewer serious side effects, and if still equal, who felt better. The share of 'wins' becomes the result.