# Publicly funded trials of lower and less frequent doses of expensive cancer drugs

Source: https://onco.cc/ideas/idea-reg-public-deescalation-trials-for-cost/  
OnCo record `idea-reg-public-deescalation-trials-for-cost` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Abiraterone at a quarter dose with food matches full-dose exposure, and pembrolizumab and nivolumab can be given at longer intervals, but no manufacturer will fund trials that cut its own revenue. A public 'value trials' fund would run non-inferiority trials of lower doses and longer intervals for the highest-spend cancer drugs, with payers committing to adopt positive results.

## Summary

Abiraterone at a quarter dose with food matched full-dose exposure; extended-interval pembrolizumab and nivolumab are supported by pharmacology; several kinase inhibitors are effective at reduced doses with less toxicity. Because no manufacturer will fund trials that cut its own revenue, these questions are answered slowly by academic groups. The proposal is a dedicated public 'value trials' fund (modelled on the Netherlands' ZonMw and the UK NIHR programmes) that prioritises dose and schedule de-escalation of the highest-spend oncology drugs using non-inferiority designs, with payers committing to adopt positive results.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: Each $10 million invested in de-escalation trials returns at least $100 million a year in payer savings within five years of readout, with non-inferior survival and lower toxicity in the de-escalated arms.
- Rationale: The return on de-escalation trials is enormous because the drugs are already widely used; the barrier is purely who pays for the trial. The Netherlands' programme has already reported savings many times its cost.
- Proposed test: Fund five non-inferiority trials targeting the five highest-spend oncology drugs in one health system, and audit realised savings and clinical outcomes at five years.
- Maturity: being-tested-at-scale
- Actor: policy

## Sources

- Bottleneck evidence (Prices and value): Prasad, De Jesús & Mailankody, The high price of anticancer drugs: origins, implications, barriers, solutions (Nat Rev Clin Oncol 2017): https://doi.org/10.1038/nrclinonc.2017.31

## Connected records

- drugs: [Nivolumab](https://onco.cc/drugs/nivolumab/), [Osimertinib](https://onco.cc/drugs/osimertinib/), [Pembrolizumab](https://onco.cc/drugs/pembrolizumab/)
- bottlenecks: [Prices and value](https://onco.cc/bottlenecks/b-drug-pricing/), [Wrong doses](https://onco.cc/bottlenecks/b-dose-optimisation/)
- key papers: [The high price of anticancer drugs: origins, implications, barriers, solutions](https://onco.cc/key-papers/paper-prasad-nat-rev-clin-oncol/)
- roadmaps: [Global access and affordability roadmap: essential medicines and generics → biosimilars and frugal trials → reliance, pooling and homegrown innovation](https://onco.cc/roadmaps/global-access-roadmap/)

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