Bottlenecks of the war on cancer

Nearly every targeted therapy stops working within months to a few years as the tumour adapts.

Most tumours keep the immune system out or asleep, so immunotherapy helps only a minority.

Records, scans, genomes and outcomes sit in separate systems that cannot talk. Every patient's experience is lost to the next.

After a 'successful' treatment, cells can sleep for years then relapse. We can barely detect them and cannot target them.

The system pays the same for a drug that adds two months as for a cure, so companies race to copy rather than to cure.

Metastasis causes about nine in ten cancer deaths but gets a small fraction of research money and almost no trials of its own.

Screening exists for only a few cancers. Pancreatic, ovarian, liver, oesophageal and most lung cancers are found when cure is unlikely.

Seven in ten cancer deaths happen in low- and middle-income countries, where radiotherapy, pathology, surgery and drugs are scarce.

Nine in ten cancer drugs that work in mice fail in humans. Our models are the reason.

Around four in ten cancers are preventable with tools we already own: vaccines, tobacco control, weight, alcohol, sun and infection control.

New cancer drugs routinely cost over $150,000 a year, often for months of benefit. Systems cannot afford them and patients go bankrupt.

The proteins that drive most cancers, such as MYC, mutant p53 and most RAS variants, still have no good drug.

A phase 3 trial takes years and hundreds of millions of dollars, and often answers a question that has already moved on.

Fewer than one in ten adults with cancer joins a trial. Trials close for lack of patients, not lack of ideas.

A tumour is many tumours. Treatments that kill most cells leave the rest to grow back, changed.

Thousands of cancer AI models are published; a handful are in clinical use, and fewer have shown they help patients.

Tests that decide who gets a drug are often not validated prospectively and are measured differently in every lab.

Patients often die of wasting or cannot tolerate the doses that would work. Treating the patient, not just the tumour, lags far behind.

Negative trials, failed drugs and abandoned programmes are rarely published, so the same mistakes are repeated.

Patients fall between specialists, wait for referrals and often do not get the treatment guidelines say they should.

Money goes to the cancers and questions that are easy or popular, not the ones that kill most or where a dollar would do most.

Most people who carry a high-risk cancer gene do not know it until they or a relative gets cancer.

Knowledge diffusion is slow: it takes years for a proven result to change what most patients receive, and no one can keep up with the literature.

Cell therapies take weeks to make for one patient and cost hundreds of thousands of dollars. Isotopes run short.

Old, cheap drugs with anti-cancer signals never get the trials they need because no one profits from the result.

Checkpoint drugs cure some patients and do nothing for most. We still cannot tell the two apart before treating.

The number of people with cancer is rising faster than the workforce trained to treat them.

Most people with cancer are over 65 but most trial patients are younger and fitter. We guess how to treat the majority.

Finding more cancer is not the same as saving lives. Screening also finds cancers that would never have hurt anyone, and treats them.

Most people who die of cancer worldwide do so without adequate pain relief.

Most patients cannot understand their options, find trials, or push back, so decisions are made for them.

Fewer than half of landmark cancer biology findings reproduce when someone else tries.

Taken together rare cancers are a fifth of all cancers, but each one alone is too small for a company to invest in.

Regulatory divergence means a drug approved in one country can take years to reach another, or never arrive.

Companies with complementary drugs rarely test them together, and data that could answer questions stays locked up.

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

Most drugs cannot cross into the brain, so brain tumours and brain metastases lag every other site.

Most academic discoveries die before anyone tests them in people because nobody funds the middle step.

There are thousands of possible drug pairs and sequences. Trials can test a few dozen a year.

Trials measure how long people live, not how they live. Side-effects are under-reported and under-treated.

Older, Black, Hispanic, Asian, rural, poor and multimorbid patients are under-represented, so results may not apply to them.

We do not reliably know what happens to patients after approval, so we cannot tell which drugs deliver in practice.

Most drug doses were chosen as the highest a person can tolerate, which is often more than they need.

Patients are sold unproven treatments and frightened away from proven ones.

Tens of millions of people live after cancer with heart damage, infertility, second cancers and fear, and few services.