# Surgery and radiotherapy cure most, get least

Source: https://onco.cc/bottlenecks/b-surgery-radiation-innovation/  
OnCo record `b-surgery-radiation-innovation` (Bottleneck). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Surgery and radiotherapy cure more people than drugs do, but attract a fraction of the research investment.

## Summary

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.

## Fields

- Kind: Bottleneck
- Last checked: 2026-09-08
- Stage: funding-incentives
- Severity: major
- Metrics: Evidence-based optimal radiotherapy utilisation rate across all cancers (proportion of patients who should receive radiotherapy at least once): ~48-52% (Barton et al., Radiotherapy and Oncology 2014); Patients with cancer who will need surgery at some point in their disease (global estimate, 2015): More than 80% (Sullivan et al., Lancet Oncology Commission on Global Cancer Surgery 2015); Melanoma-specific survival benefit of completion lymphadenectomy after a positive sentinel node (MSLT-II), a practice used for decades before it was tested: None (86% in both arms at 3 years) (Faries et al., NEJM 2017)
- Causes: Surgical and radiotherapy techniques are not patentable, so no company funds their trials.; Procedures are operator-dependent and hard to standardise or blind in trials.; Surgeons and radiation oncologists have less protected research time and fewer trial units than medical oncology.; Funders and journals give more weight to molecular novelty than to technique or process innovation.; Equipment vendors fund device-specific studies, not comparative trials of strategy.

## Sources

- Sullivan et al., Global cancer surgery (Lancet Oncology Commission 2015): https://doi.org/10.1016/S1470-2045(15)00223-5
- Atun et al., Expanding global access to radiotherapy (Lancet Oncology Commission 2015): https://doi.org/10.1016/S1470-2045(15)00222-3
- Barton et al., Estimating the demand for radiotherapy from the evidence (Radiotherapy and Oncology 2014): https://doi.org/10.1016/j.radonc.2014.03.024
- McCulloch et al., No surgical innovation without evaluation: the IDEAL recommendations (Lancet 2009): https://doi.org/10.1016/S0140-6736(09)61116-8

## Connected records

- ideas: [A consented commons of surgical video linked to pathology and outcomes](https://onco.cc/ideas/idea-data-surgical-video-commons/), [A coordinated FLASH radiotherapy evidence programme with shared dose-rate standards](https://onco.cc/ideas/idea-fund-flash-evidence-programme/), [A funded programme of organ-preservation trials to avoid radical surgery](https://onco.cc/ideas/idea-fund-organ-preservation-programme/), [A national repository of radiotherapy dose plans linked to outcomes](https://onco.cc/ideas/idea-data-radiotherapy-dose-repository/), [A neutral platform trial for radiotherapy plus immunotherapy combinations](https://onco.cc/ideas/idea-fund-rt-io-platform/), [A permanently funded international network for randomised cancer surgery trials](https://onco.cc/ideas/idea-fund-surgical-trials-network/), [A pragmatic trial network for intraoperative margin tools, paid on margin reduction](https://onco.cc/ideas/idea-fund-intraoperative-imaging-trials/), [A radiotherapy-free cure for early Hodgkin lymphoma that actually holds](https://onco.cc/ideas/lymphoma-ev-radiotherapy-free-early-hodgkin/), [A randomised trial of adjuvant chemoradiation after margin-positive or node-positive gallbladder cancer resection](https://onco.cc/ideas/idea-gbc-randomised-adjuvant-chemoradiation-r1-node-positive/), [A regulatory pathway for new radiotherapy techniques modelled on drug development](https://onco.cc/ideas/idea-fund-radiotherapy-innovation-pathway/), [A standing platform for testing new drugs with radiotherapy](https://onco.cc/ideas/idea-tr2-rt-drug-platform/), [A statutory minimum share of public trial money for surgery and radiotherapy](https://onco.cc/ideas/idea-fund-non-drug-trial-quota/), [A translation fund for academic surgical devices and radiotherapy technology](https://onco.cc/ideas/idea-fund-device-and-technique-translation-fund/), [A trial of sparing the liver resection in peritoneal-side (T2a) gallbladder cancer](https://onco.cc/ideas/idea-gbc-t2a-spare-liver-resection-trial/), [A video-based surgical quality registry linking assessed skill to cancer outcomes](https://onco.cc/ideas/idea-fund-surgical-video-registry/), [Advanced-practice radiation therapists doing contouring and on-treatment reviews](https://onco.cc/ideas/idea-acc-advanced-practice-radiation-therapists/), [An independent evaluation unit for surgical robots and AI, paid on evidence](https://onco.cc/ideas/idea-fund-surgical-ai-robotics-evaluation/), [An open-hardware radiotherapy machine built for unreliable power and dust](https://onco.cc/ideas/idea-acc-open-hardware-linac/), [Bladder preservation for MIBC after perioperative EV + pembrolizumab complete response](https://onco.cc/ideas/idea-bladder-preservation-mibc/), [Blended finance and a low-cost linac to close the global radiotherapy gap](https://onco.cc/ideas/idea-fund-lmic-radiotherapy-finance/), [Chemotherapy before surgery for every resectable pancreatic cancer, settled by the two perioperative trials rather than assumed](https://onco.cc/ideas/idea-pdac-neoadjuvant-chemotherapy-for-all-resectable-disease/), [Compact FLASH and proton systems at the price of a conventional linac](https://onco.cc/ideas/idea-moon-compact-flash-proton/), [Core-funded radiotherapy trials infrastructure with central quality assurance](https://onco.cc/ideas/idea-fund-radiotherapy-trials-infrastructure/), [Coverage-with-evidence registries for MR-guided and adaptive radiotherapy](https://onco.cc/ideas/idea-fund-adaptive-radiotherapy-evidence/), [Device-agnostic public trials of ablation technologies against surgery](https://onco.cc/ideas/idea-fund-ablation-versus-surgery-trials/), [Find peritoneal spread while it is still small, and run complete cytoreduction through networks rather than adding heated chemotherapy](https://onco.cc/ideas/idea-crc-peritoneal-disease-found-early-and-treated-in-networks/), [Funded research pathways for surgeon-scientists and radiation oncologist-scientists](https://onco.cc/ideas/idea-fund-surgeon-scientist-pathway/), [Geriatrician co-management for older patients having cancer surgery](https://onco.cc/ideas/idea-acc-geriatric-co-management-surgery/), [Low-cost cobalt-60 brachytherapy for cervical cancer in every regional centre](https://onco.cc/ideas/idea-acc-frugal-hdr-brachytherapy/), [Make one-week radiotherapy the default in overloaded systems](https://onco.cc/ideas/idea-acc-hypofractionation-default-lmic/), [Mandatory staged registries for new surgical techniques before wide adoption](https://onco.cc/ideas/idea-fund-device-technique-registry/), [Mechanically pulverise one tumour with ultrasound to wake the immune system](https://onco.cc/ideas/idea-bio2-histotripsy-immune-priming/), [Modernised cobalt-60 machines as a deliberate bridge where linacs cannot be kept running](https://onco.cc/ideas/idea-acc-modern-cobalt-bridge/), [Multimodal prehabilitation for older patients before major cancer surgery](https://onco.cc/ideas/idea-acc-prehabilitation-older-surgery/), [Organ preservation as the default after complete response in oesophageal cancer](https://onco.cc/ideas/idea-organ-preservation-esophageal/), [Pay for a course of radiotherapy, not for each fraction](https://onco.cc/ideas/idea-cost-hypofractionation-payment/), [Pay for radiotherapy machine uptime, not for the machine](https://onco.cc/ideas/idea-acc-linac-uptime-contracts/), [Pay per course of radiotherapy, not per session, so short courses are not penalised](https://onco.cc/ideas/idea-fund-course-based-radiotherapy-payment/), [Payer-funded trials that omit surgery or radiotherapy in low-risk patients](https://onco.cc/ideas/idea-fund-omission-deescalation-trials/), [Pick the radiation dose that switches the immune alarm on, not off](https://onco.cc/ideas/idea-bio2-radiotherapy-sting-fractionation/), [Pooled coverage-with-evidence for proton therapy across all centres](https://onco.cc/ideas/idea-fund-proton-coverage-with-evidence/), [Prizes for unpatentable surgical and radiotherapy techniques proven in trials](https://onco.cc/ideas/idea-fund-technique-innovation-prize/), [Public risk-adjusted outcome reporting for cancer surgery to drive centralisation](https://onco.cc/ideas/idea-fund-surgical-outcomes-public-reporting/), [Publish a per-lesion miss rate for every prostate MRI service before it is allowed to guide focal treatment](https://onco.cc/ideas/idea-prostate-per-lesion-mri-audit-before-focal-treatment/), [Radiotherapy for everyone who needs it by 2040](https://onco.cc/ideas/idea-moon-radiotherapy-for-everyone-2040/), [Randomise organ preservation against surgery in mismatch repair-proficient rectal cancer, with bowel function as a co-primary endpoint](https://onco.cc/ideas/idea-crc-organ-preservation-randomised-in-pmmr-rectal/), [Real-time margin assessment and image-guided surgery as the global standard](https://onco.cc/ideas/idea-moon-image-guided-surgery-everywhere/), [Robot-placed catheters and live imaging for drug infusion into brain tumours](https://onco.cc/ideas/idea-bio2-robotic-convection-delivery/), [Single-fraction radiotherapy as the default for painful bone metastases](https://onco.cc/ideas/idea-acc-single-fraction-palliative-radiotherapy-default/), [Structured mentorship so district general surgeons perform common cancer operations safely](https://onco.cc/ideas/idea-acc-district-surgeon-oncology-mentorship/), [Test whether T1b gallbladder cancer needs the second operation at all](https://onco.cc/ideas/idea-gbc-t1b-simple-cholecystectomy-prospective-study/), [Use LET, RBE and alpha/beta to decide when protons beat IMRT](https://onco.cc/ideas/idea-bio2-let-rbe-ab-selects-protons/), [Validate and reimburse AI contouring and planning to expand radiotherapy capacity](https://onco.cc/ideas/idea-fund-rt-planning-ai-capacity/)
- cancers: [Bladder & urothelial cancer](https://onco.cc/cancers/urothelial/), [Cervical cancer](https://onco.cc/cancers/cervical/), [Melanoma](https://onco.cc/cancers/melanoma/), [Mesothelioma](https://onco.cc/cancers/mesothelioma/), [Oesophageal cancer](https://onco.cc/cancers/esophageal/), [Prostate cancer](https://onco.cc/cancers/prostate/), [Renal cell carcinoma](https://onco.cc/cancers/rcc/)
- fronts: [Radiation Therapy](https://onco.cc/fronts/radiation/), [Surgery & Interventional](https://onco.cc/fronts/surgery/)
- technologies: [Brachytherapy](https://onco.cc/technologies/brachytherapy/), [BREAST-Q and the Q-portfolio: measuring what an operation left behind](https://onco.cc/technologies/rejuv-measure-breast-q/), [Carbon-ion therapy](https://onco.cc/technologies/carbon-ion/), [Enhanced recovery (ERAS) and perioperative nutrition](https://onco.cc/technologies/eras-perioperative-nutrition/), [Extended pleurectomy/decortication & radical mesothelioma surgery](https://onco.cc/technologies/pleurectomy-decortication/), [FLASH radiotherapy](https://onco.cc/technologies/flash-rt/), [Fluorescence-guided surgery](https://onco.cc/technologies/fluorescence-guided-surgery/), [Immunonutrition before cancer surgery](https://onco.cc/technologies/immunonutrition-perioperative/), [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [Linac, proton system and brachytherapy machine manufacturing](https://onco.cc/technologies/radiotherapy-equipment-manufacturing/), [MR-guided adaptive radiotherapy](https://onco.cc/technologies/mr-linac/), [Proton therapy](https://onco.cc/technologies/proton-therapy/), [Robotic & minimally invasive surgery](https://onco.cc/technologies/robotic-surgery/), [SBRT / SABR (stereotactic radiotherapy)](https://onco.cc/technologies/sbrt/), [Sentinel lymph node biopsy](https://onco.cc/technologies/sentinel-node/)
- companies: [Elekta](https://onco.cc/companies/elekta/), [EORTC](https://onco.cc/companies/curie-nki-eortc/), [Intuitive Surgical](https://onco.cc/companies/intuitive-surgical/), [Japan Clinical Oncology Group (JCOG)](https://onco.cc/companies/jcog/), [NRG Oncology](https://onco.cc/companies/nrg-oncology/), [RefleXion Medical](https://onco.cc/companies/reflexion/), [Varian (Siemens Healthineers)](https://onco.cc/companies/varian/)
- institutions: [Aarhus University Hospital](https://onco.cc/institutions/aarhus-university-hospital/), [Advanced Research Projects Agency for Health](https://onco.cc/institutions/arpa-h/), [American Society for Radiation Oncology](https://onco.cc/institutions/astro/), [Cancer Research UK](https://onco.cc/institutions/cruk/), [European Society for Radiotherapy and Oncology](https://onco.cc/institutions/estro/), [European Society of Surgical Oncology](https://onco.cc/institutions/esso/), [International Atomic Energy Agency: Rays of Hope](https://onco.cc/institutions/iaea/), [Society of Surgical Oncology](https://onco.cc/institutions/sso/), [The Royal Marsden](https://onco.cc/institutions/royal-marsden/)
- trials: [CROSS](https://onco.cc/trials/cross/), [Elective vs therapeutic neck dissection in node-negative oral cancer (Tata Memorial)](https://onco.cc/trials/elective-neck-dissection-tmh/), [FORTplus](https://onco.cc/trials/fortplus/), [LACC (Laparoscopic Approach to Cervical Cancer)](https://onco.cc/trials/lacc/), [MARS 2](https://onco.cc/trials/mars-2/), [MSLT-II](https://onco.cc/trials/mslt-ii/), [Peritumoral lidocaine before breast cancer surgery (Tata Memorial)](https://onco.cc/trials/lidocaine-peritumoral-tmh/), [PREHAB: multimodal prehabilitation before colorectal cancer surgery](https://onco.cc/trials/prehab-trial/), [ProtecT](https://onco.cc/trials/protect/), [SANO](https://onco.cc/trials/sano/), [Single-injection depot progesterone before breast surgery (Tata Memorial)](https://onco.cc/trials/progesterone-preop-tmh/), [TROG 99.03](https://onco.cc/trials/trog-99-03/)
- key papers: [ADRIATIC: durvalumab after chemoradiotherapy for limited-stage small-cell lung cancer](https://onco.cc/key-papers/paper-adriatic-nejm-2024/), [Cercek 2022: six months of dostarlimab alone made rectal cancer disappear in every patient with mismatch-repair deficiency](https://onco.cc/key-papers/paper-cercek-dostarlimab-rectal-nejm-2022/), [Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy versus cytoreductive surgery alone for colorectal peritoneal metastases (PRODIGE 7)](https://onco.cc/key-papers/paper-quenet-prodige-7-hipec-peritoneal-colorectal-lancet-oncol-2021/), [Detection of individual prostate cancer foci via multiparametric magnetic resonance imaging](https://onco.cc/key-papers/paper-johnson-mpmri-individual-foci-eur-urol-2019/), [Elective versus therapeutic neck dissection in node-negative oral cancer](https://onco.cc/key-papers/paper-dcruz-elective-neck-dissection-nejm-2015/), [Estimating the demand for radiotherapy from the evidence: a review of changes from 2003 to 2012](https://onco.cc/key-papers/paper-barton-radiother-oncol/), [Expanding global access to radiotherapy](https://onco.cc/key-papers/paper-atun-lancet-oncol/), [Five-year survival outcomes from the PACIFIC trial: durvalumab after chemoradiotherapy in stage III non-small-cell lung cancer](https://onco.cc/key-papers/paper-spigel-pacific-five-year-survival-jco-2022/), [Global cancer surgery: delivering safe, affordable, and timely cancer surgery](https://onco.cc/key-papers/paper-sullivan-lancet-oncol/), [Improved survival with preoperative radiotherapy in resectable rectal cancer (Swedish Rectal Cancer Trial)](https://onco.cc/key-papers/paper-swedish-rectal-cancer-trial-preoperative-radiotherapy-nejm-1997/), [NADINA: two doses of ipilimumab plus nivolumab before surgery beat a year of nivolumab after surgery in stage III melanoma](https://onco.cc/key-papers/paper-nadina-nejm-2024/), [NICHE-2: a month of nivolumab and ipilimumab before surgery clears mismatch-repair-deficient colon cancer in most patients](https://onco.cc/key-papers/paper-niche-2-nejm-2024/), [No surgical innovation without evaluation: the IDEAL recommendations](https://onco.cc/key-papers/paper-mcculloch-lancet/), [Nomogram for predicting the benefit of adjuvant chemoradiotherapy for resected gallbladder cancer](https://onco.cc/key-papers/paper-wang-adjuvant-chemoradiotherapy-nomogram-gallbladder-cancer-jco-2011/), [Nonoperative management of mismatch repair-deficient tumors](https://onco.cc/key-papers/paper-cercek-nonoperative-management-mismatch-repair-deficient-tumours-nejm-2025/), [Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results](https://onco.cc/key-papers/paper-habr-gama-nonoperative-stage-0-rectal-ann-surg-2004/), [Organ preservation in patients with rectal adenocarcinoma treated with total neoadjuvant therapy (OPRA)](https://onco.cc/key-papers/paper-garcia-aguilar-opra-organ-preservation-jco-2022/), [PACIFIC: a year of durvalumab after chemoradiotherapy for stage III lung cancer](https://onco.cc/key-papers/paper-pacific-nejm-2017/), [Perioperative nivolumab and chemotherapy in stage III non-small-cell lung cancer](https://onco.cc/key-papers/paper-provencio-nadim-ii-perioperative-nivolumab-stage-iii-nejm-2023/), [Preoperative chemotherapy for operable colon cancer: mature results of an international randomized controlled trial (FOxTROT)](https://onco.cc/key-papers/paper-foxtrot-preoperative-chemotherapy-colon-jco-2023/), [Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer (Dutch TME trial)](https://onco.cc/key-papers/paper-kapiteijn-dutch-tme-preoperative-radiotherapy-nejm-2001/), [Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016)](https://onco.cc/key-papers/paper-sebag-montefiore-cr07-preoperative-radiotherapy-lancet-2009/), [Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer](https://onco.cc/key-papers/paper-verwaal-cytoreduction-hipec-peritoneal-colorectal-jco-2003/), [Short-course radiotherapy followed by chemotherapy before total mesorectal excision versus preoperative chemoradiotherapy in locally advanced rectal cancer (RAPIDO)](https://onco.cc/key-papers/paper-bahadoer-rapido-short-course-radiotherapy-lancet-oncol-2021/), [SPCG-4: radical prostatectomy or watchful waiting in prostate cancer, 29-year follow-up](https://onco.cc/key-papers/paper-bill-axelson-spcg-4-29-year-nejm-2018/), [SunRISe-1: TAR-200, a gemcitabine-releasing device placed in the bladder, for BCG-unresponsive non-muscle-invasive bladder cancer](https://onco.cc/key-papers/paper-sunrise-1-jco-2025/), [SWOG S0809: A Phase II Intergroup Trial of Adjuvant Capecitabine and Gemcitabine Followed by Radiotherapy and Concurrent Capecitabine in Extrahepatic Cholangiocarcinoma and Gallbladder Carcinoma](https://onco.cc/key-papers/paper-swog-s0809-adjuvant-chemoradiation-jco-2015/), [The mesorectum in rectal cancer surgery: the clue to pelvic recurrence?](https://onco.cc/key-papers/paper-heald-mesorectum-rectal-cancer-surgery-br-j-surg-1982/), [Twice-daily compared with once-daily thoracic radiotherapy in limited small-cell lung cancer treated concurrently with cisplatin and etoposide](https://onco.cc/key-papers/paper-turrisi-twice-daily-thoracic-radiotherapy-limited-sclc-nejm-1999/)
- roadmaps: [Colorectal cancer roadmap: from the adenoma-carcinoma sequence and the first screening trials to total mesorectal excision, oxaliplatin, RAS testing, immunotherapy for mismatch repair-deficient disease, ctDNA-guided treatment and organ preservation](https://onco.cc/roadmaps/colorectal-roadmap/), [Devices and physical therapies roadmap: heat and light → electric fields and focused sound → drug-releasing implants](https://onco.cc/roadmaps/devices-roadmap/), [Pancreatic cancer roadmap: from Whipple's operation to gemcitabine, FOLFIRINOX, adjuvant chemotherapy, PARP inhibition, KRAS inhibition, vaccines and the surveillance question](https://onco.cc/roadmaps/pancreatic-roadmap/), [Radiotherapy roadmap: X-rays → shaped beams → fewer fractions, particles and FLASH](https://onco.cc/roadmaps/radiation-roadmap/), [Surgery roadmap: radical operations → less surgery → no surgery when a drug has done the work](https://onco.cc/roadmaps/surgery-roadmap/)
- terms: [Choices made at the time of treatment that change the second cancer risk](https://onco.cc/terms/rejuv-second-choices-made-at-treatment/), [Prehabilitation (the pre-treatment window)](https://onco.cc/terms/prehabilitation-term/), [Radiotherapy and second cancers: field, dose and age at exposure](https://onco.cc/terms/rejuv-second-radiotherapy-dose-field-and-age/), [Whole-mount pathology](https://onco.cc/terms/whole-mount-pathology/)
- pairings: [Caution: proton therapy vs IMRT](https://onco.cc/pairings/proton-vs-imrt/)
- people: [Ashya King](https://onco.cc/people/ashya-king/), [Bernard Fisher](https://onco.cc/people/bernard-fisher/), [Goh Cheng Liang](https://onco.cc/people/goh-cheng-liang/)

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