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Seven in ten cancer deaths happen in countries with almost no cancer care, and even rich systems cannot afford every new drug. The roadmap is the set of levers that already work, from generics and biosimilars to trials that cut the dose, and the ones being built: regulators trusting each other's reviews, pooled purchasing, and drugs and cell therapies made where patients live.
The first levers were policy: the WHO Essential Medicines List, generic manufacturing in India, and compulsory licensing when a patent priced a drug out of reach (Natco v Bayer, 2012). Biosimilars of trastuzumab and rituximab, on the market since 2017, cut the price of HER2 and lymphoma treatment by large fractions, and India's National Cancer Grid showed that pooled procurement across hundreds of hospitals lowers prices further.
The second lever is frugal evidence. Tata Memorial's trials showed that a twentieth of a nivolumab dose added to cheap metronomic chemotherapy improves survival in head and neck cancer, that oral metronomic tablets match intravenous cisplatin, and that a single cheap progesterone injection before breast surgery helps; INTERLACE, PERSEPHONE and FAST-Forward showed that cheaper schedules of existing treatments are as good. India and China now develop their own: India's first CAR-T (NexCAR19) at a fraction of the Western price, an Indian HPV vaccine, and Chinese PD-1 antibodies and ADCs that have gone from domestic approval to beating Western standards head to head.
The next levers are institutional: regulators accepting each other's reviews (Project Orbis, reliance pathways), WHO prequalification and pooled demand for biosimilars, patent pools for essential cancer drugs, public cell-therapy manufacturing, pooled procurement of radiotherapy, and prices anchored to measured clinical benefit. The pace is set by pricing power, regulatory divergence, workforce, and the near-absence of pain relief where most people die of cancer.
The WHO Essential Medicines List, first published in 1977, told health systems what to buy first; India's process-patent regime and companies such as Cipla, Natco and Dr Reddy's supplied the generics; and when a patented liver cancer drug was priced beyond reach, India issued its first compulsory licence (Natco v Bayer, 2012). Tobacco control, hepatitis B vaccination and cheap curative chemotherapy for childhood leukaemia and testicular cancer were the interventions that travelled.
Trastuzumab biosimilars, approved from 2017 with Biocon and Mylan's first, and rituximab biosimilars cut the price of two of the most important cancer antibodies by large fractions where they were adopted; in Europe, biosimilar-first defaults did most of the work. India's National Cancer Grid, run from Tata Memorial and linking more than 360 centres, showed that pooled procurement across hospitals lowers prices further and standardises what is bought.
Tata Memorial randomised the questions no company would fund: about a twentieth of a nivolumab dose added to cheap oral metronomic chemotherapy improved survival in head and neck cancer, oral metronomic tablets matched intravenous cisplatin, a single depot progesterone injection before breast surgery helped, and elective neck dissection was proven over watchful waiting. In the UK, PERSEPHONE showed six months of trastuzumab is nearly as good as twelve with half the heart toxicity, FAST-Forward cut breast radiotherapy to one week, and INTERLACE cut cervical cancer deaths with six weeks of generic chemotherapy. Each is usable anywhere; the task is getting them into labels and guidelines.
India approved its first CAR-T, NexCAR19, developed at IIT Bombay and Tata Memorial and priced at a fraction of Western products; Immuneel ran the first industry CAR-T trial in India; the Serum Institute launched an Indian HPV vaccine. China's PD-1 antibodies (sintilimab, camrelizumab, toripalimab) were approved domestically at prices set by national negotiation and then taken global; its CAR-Ts and HER2 ADCs followed; and ivonescimab became the first drug to beat pembrolizumab head to head (HARMONi-2). The centre of gravity of affordable innovation is moving.
One round of HPV testing in rural Indian villages cut cervical cancer deaths (Osmanabad); trained health workers with a torch found mouth cancers early in tobacco users (Kerala); vinegar and a lamp screened women in Mumbai slums. A single HPV vaccine dose proved almost fully protective (an interrupted Indian trial, then KEN SHE), and self-collected swabs with same-day thermal ablation let nurses run cervical programmes without colposcopy. These are the interventions with the highest return per dollar in oncology.
Project Orbis lets the FDA and partner regulators review together; the proposals extend it to a shared assessment report and a 90-day reliance approval for drugs cleared by two stringent regulators. WHO prequalification plus pooled demand could push biosimilar prices below a tenth of the originator; an advance market commitment could do the same for PD-1 biosimilars; Medicines Patent Pool licences for every patented drug on the essential list and tiered-price pledges tied to listing would formalise it. Public-sector CAR-T manufacturing in India, Brazil and South Africa, pooled procurement of radiotherapy machines with uptime contracts, and a Global Fund for cancer are the capital-intensive versions.
New cancer drugs routinely cost more than a house per year, often for months of benefit, and systems cannot afford them without rationing. The levers: prices anchored to the ESMO and ASCO benefit scales and revisited when survival data mature, a different price for the same drug in different indications, publicly funded de-escalation trials of expensive drugs, biosimilar-first defaults, a non-profit manufacturer for generics in shortage, and screening every patient for financial toxicity as a vital sign. The costs page on this site pairs each driver with what is already being done.
Drugs do not treat patients; people do, and most of the world has too few oncologists, pathologists, physicists and nurses. Community health workers trained in triage, navigation and home palliative care, Project ECHO tele-mentoring for district clinicians, remote radiotherapy planning hubs, diaspora tumour boards, and opioid quota reform so morphine reaches people dying of cancer are the workforce answers. A population registry as a condition of every aid programme, burden-matched trial funding and pivotal-trial sites in Africa, South Asia and Latin America would make progress measurable. A ten-dollar blood test for the five cancers that kill most people in poorer countries is the diagnostic bet.
Seven in ten cancer deaths happen where radiotherapy, pathology and essential drugs are scarce or absent. Prices are set by what the richest payer will bear, regulators duplicate each other's reviews so approvals lag by years, old cheap drugs have no sponsor to test them, trials rarely include the populations that carry the burden, and most people who die of cancer worldwide do so without adequate pain relief. Every lever above attacks one of these.
Every era's records, trial outcomes and papers, and every watch item, as JSON.
Probability ranges are named estimates that the claim is borne out on roughly a five-year horizon. They are meant to be argued with: propose a revision with your name and reasoning via a pull request to src/data/confidence.ts.
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One roadmap page on OnCo cites this paper by its DOI; this record gives the citation a page of its own so a reader can follow it without leaving OnCo. Read the abstract above alongside the citing page listed under Related; the record was created automatically from the Europe PMC entry and its figures have not been checked by hand.
The deprivation gradient in lung cancer is not only about who gets the disease. Among people who already have it, and at the same stage, poorer patients are less likely to be offered the treatment that works.
Shares A joint price negotiation bloc for middle-income countries, modelled on Beneluxa, Grant extra exclusivity only in exchange for binding low prices in poorer countries, Biosimilar-first defaults and payment parity in every cancer day unit, Cap public prices for new cancer drugs to tiers of the ESMO and ASCO value scales.
Shares Oral cancer visual screening, HPV self-testing with same-day treatment as the national cervical programme, Mumbai VIA cervical screening trial (Tata Memorial), Osmanabad cervical screening trial (HPV testing vs cytology vs VIA).
Shares Oral cancer visual screening, Elective vs therapeutic neck dissection in node-negative oral cancer (Tata Memorial), Kerala oral cancer visual screening trial (Trivandrum), METRO PLUS (Tata Memorial Centre, Varanasi).
Shares KEN SHE (single-dose HPV vaccine), CERVAVAC (quadrivalent HPV vaccine, India), IARC India HPV vaccine dose study (one, two or three doses), Thermal ablation and cryotherapy for cervical precancer.
Shares Immuneel Therapeutics, IMAGINE (varnimcabtagene autoleucel, Immuneel), Varnimcabtagene autoleucel, ImmunoACT.
Shares National Healthcare Security Administration, WHO Essential Medicines List for cancer, Health technology assessment (HTA), reimbursement and QALYs, Biosimilar.
Shares Publicly funded trials of lower and less frequent doses of expensive cancer drugs, Low-dose immunotherapy in head and neck cancer: a randomised study (Tata Memorial), Fund trials that test shorter courses of the most expensive adjuvant drugs, IARC India HPV vaccine dose study (one, two or three doses).
Shares Low-cost cobalt-60 brachytherapy for cervical cancer in every regional centre, Community health workers trained in cancer triage, navigation and home palliative care, HPV self-testing with same-day treatment as the national cervical programme, Validate low-cost metronomic oral regimens in phase 3 and carry them into guidelines.