Prices and value
New cancer drugs routinely cost over $150,000 a year, often for months of benefit. Systems cannot afford them and patients go bankrupt.
Launch prices of new cancer drugs in the US have risen far faster than inflation or benefit, and analyses across the US and Europe find no correlation between price and clinical benefit as graded by ESMO-MCBS or the ASCO framework. The median survival gain of drugs approved in the early 2010s was about two months, while annual prices exceeded US$100,000 and now often exceed US$150,000-200,000. Financial toxicity is a measurable side-effect: US patients with cancer are more than twice as likely to declare bankruptcy as matched controls, and bankruptcy itself predicts earlier death. Publicly funded systems respond by delay, restriction or refusal, so a drug's availability depends on the country and payer rather than on the evidence. Value-based pricing, reference pricing, negotiation, biosimilar competition and transparent benefit grading are the levers; none has yet changed the launch-price trajectory.
- Patent monopolies and inelastic demand allow prices to be set at what payers will bear rather than at value.
- US Medicare was prohibited from negotiating drug prices until 2022, anchoring global reference prices.
- Approval does not require demonstration of benefit relative to price, and surrogate-based approvals are priced like cures.
- Fragmented payers lack bargaining power and information about comparative value.
- Follow-on products are priced at or above the incumbent rather than competing on price.
- The US Inflation Reduction Act (2022) allows Medicare to negotiate prices for selected high-spend drugs, with the first negotiated prices effective in 2026 and oncology drugs (ibrutinib, others) in early rounds.
- ESMO-MCBS and the ASCO Value Framework give payers and clinicians a standardised grade of clinical benefit.
- NICE, Germany's AMNOG, and EU joint clinical assessments tie reimbursement to demonstrated added benefit.
- Biosimilars of trastuzumab, bevacizumab and rituximab have cut prices substantially in Europe and the US.
- The Experts in Chronic Myeloid Leukemia letter (Blood 2013) and Common Sense Oncology are clinician-led campaigns against price-benefit disconnect.
- The WHO Essential Medicines List and Access to Oncology Medicines (ATOM) Coalition push affordable access to essential cancer medicines in low- and middle-income countries.
When two expensive cancer drugs are combined, the price is often the sum of both even though the extra benefit is smaller. A rule for splitting the total value between them is needed.
Instead of letting a company charge more for a newly proven use of an old drug, payers would pay a one-off reward and keep the price low for everyone.
Countries buying radiotherapy machines one at a time pay high prices and get poor service. A single global buyer negotiating for dozens of machines a year could cut prices and demand long-term support.
Companies could choose to sell a new cancer drug at cost worldwide and instead be paid from a pooled fund according to how much health it actually delivers.
Small European countries have started negotiating cancer drug prices together. A bloc of large middle-income countries would have far more bargaining power.
Cheap, essential chemotherapy drugs like cisplatin run out because making them is not profitable enough. A non-profit maker could guarantee supply at a fair price.
Once a class of antibody such as PD-1 blockers is proven, later copies could be approved on smaller trials showing equivalence, forcing price competition and freeing patients and money for genuinely new drugs.
Immunotherapy patents start expiring around 2028. Guaranteeing in advance to buy cheap copies for poorer countries would make sure manufacturers build the capacity.
Countries negotiate secret discounts, so nobody knows what anyone actually pays for a cancer drug. Sharing real prices between public buyers would strengthen every negotiation.
Copies of biological cancer drugs are still required to run large trials that rarely change the answer. Dropping them would cut years and tens of millions from each biosimilar.
When a cancer drug is approved for more uses, the company sells far more of it but the price stays the same. Japan cuts prices automatically when sales balloon; others should too.
Cheaper copies of biological cancer drugs exist but are used far less in some countries than others. Making them the default choice saves billions with no loss of benefit.
Pay hospitals a single amount for a whole course of cancer treatment, with extra for following the evidence, rather than paying per visit and per drug, which rewards fragmentation.
Governments could pay a company a large one-off sum for the rights to a highly effective cancer drug, then let anyone make it cheaply for everyone.
Oncology societies already grade how much benefit each new drug gives. Payers should tie the maximum price they pay to that grade.
A trial in India found that adding a very small dose of an immunotherapy drug, about a twentieth of the usual amount, to chemotherapy improved survival in head and neck cancer. If confirmed, this could make immunotherapy affordable for millions.
Taxpayers fund much of the science behind new cancer drugs but never learn what they cost to develop. Disclosure should be a condition of public payment.
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.
Health systems would pay for a $400,000 cell therapy only if it works. If the cancer has not responded by three months, the company refunds the price.
Companies get longer monopolies for rare and paediatric cancer drugs. That reward should come with a commitment to sell at cost in low-income countries.
Academic hospitals can already make CAR-T cells for a fraction of the commercial price. A public network would scale that so more patients can be treated for less.
Instead of shipping a patient's cells to a distant factory, hospitals would make CAR-T on site under a shared licence, cutting cost and waiting time.
Instead of making cell therapy from each patient's own cells in a factory, inject a particle that reprograms immune cells inside the body, made in bulk, so a dose costs thousands rather than hundreds of thousands.
Pay more for drugs that clearly help people live longer or better, and less for those that barely move the needle, using a public benefit scale doctors already use.
Companies extend monopolies on cancer drugs with dozens of minor patents and deals that pay generic makers to stay out. Closing these loopholes would bring cheaper versions years earlier.
Companies can license their patents to generic makers for poorer countries through a UN-backed pool, as happened for HIV. Only one cancer drug has been licensed so far; the whole essential list should be.
Regulators want proof a drug works; payers want proof it is worth the price. Agreeing both requirements at once would stop drugs being approved but then not paid for.
Instead of paying hundreds of thousands up front for a CAR-T or gene therapy, the health system would pay in yearly instalments that stop if the cancer comes back, so companies are paid for cures, not attempts.
One immunotherapy may add years of life in one cancer and weeks in another, yet costs the same. Prices should track the benefit in each use.
Insurers pay for many cancer tests that have never been shown to improve outcomes. Paying only inside studies that measure whether the test helps would sort the useful from the useless.
A single cell therapy can cost more than a house. Paying in yearly instalments, only while the patient stays well, spreads the cost and shares the risk.
For very expensive one-time treatments such as CAR-T, pay in instalments over years and stop paying if the cancer comes back, so price tracks the cure actually delivered.
Insurers already pay for many untested drug combinations. Paying only when the patient joins a simple randomised comparison would turn that spending into evidence.
When a health system pays for a new, uncertain cancer drug, it would require that every patient's outcome is recorded and that a pre-agreed analysis decides whether payment continues.
Health insurers and national health systems have every reason to find out whether half the dose or half the duration of a costly drug works as well. They would fund those trials directly 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.
Vaccines tailored to each patient's tumour mutations are showing real benefit but cost a fortune to make. Automate the whole process so a personalised vaccine costs about as much as a course of chemotherapy.
Custom cancer vaccines take weeks to make and work best when there is very little disease. Making one at surgery and giving it when a blood test turns positive matches both facts.
Proton therapy costs far more than standard radiotherapy and, for most adult cancers, nobody knows whether it is better. Payers would cover it only inside trials or registries that answer that question, across every centre at once.
Countries buying cancer drugs alone pay more and face shortages. Buying together, as they already do for childhood cancer drugs and vaccines, cuts prices and secures supply.
Buy essential cancer drugs for many countries at once and license newer ones to generic makers, as was done for HIV, so prices fall to what those health systems can pay.
A trial can be designed to detect a tiny improvement that is statistically real but too small to matter. Protocols should state up front what size of benefit would be worth having, and be built to detect that.
Drugs approved on early signs of benefit are paid for as if they had proved they extend life. Pay a provisional price and adjust it, up or down, when the survival data come in.
Hospitals in Spain make their own CAR-T for a third of the commercial price. Paying for such products at cost gives health systems a lever in negotiating with companies.
Cheap, essential chemotherapy drugs such as cisplatin keep running short because there is little profit in making them. A publicly-backed non-profit manufacturer would guarantee supply at a fair price.
Many approved cancer drugs probably work just as well at half the dose, which would halve their side effects and cost. Companies will not test this, so payers and public funders should.
Many cancer drugs work as well at lower doses or given less often, but companies have no reason to prove it. Public funders should run those trials.
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.
Set the price of a new cancer drug provisionally, then adjust it up or down after three years depending on how well patients actually did.
Immunotherapy is given as one flat dose regardless of body size, which means smaller patients get more than they need. Dosing by weight would save a fifth of the drug at no cost to patients.
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.
Cancer often ruins families financially, and money worries make people skip treatment. Ask about finances at the first visit, as routinely as asking about allergies, and route people to assistance.
Ask about money problems with a short validated questionnaire when treatment starts, and route those at risk to financial navigators before bills cause missed doses.
The fifth PD-1 antibody that is no better than the first should not get the same market protection as the first. Exclusivity would shrink for copies that add nothing.
Hospitals often lack the staff to switch patients to cheaper equivalent drugs. Private investors could fund the switching teams and be repaid by the health system from the money saved.
Instead of paying per dose, a country would pay a fixed annual fee and treat every eligible patient with immunotherapy. This has worked for hepatitis C drugs and antibiotics.
Many antibody drugs moved from doses based on body weight to one fixed dose for everyone, which is convenient but means lighter patients get relatively more drug. Trials comparing the two, plus rounding doses to standard vial sizes, could keep effectiveness while cutting cost and waste.
When a cancer drug is added to the WHO essential medicines list, the maker should publicly commit to a low price and reliable supply for poorer countries, or the listing is withheld.
Reward companies that deliver a genuinely new kind of cancer drug with a sellable voucher for faster review of another product, but only if they agree to fair pricing and global access.
Scans at three months often cannot tell whether immunotherapy is working. A blood test at six weeks may give a clearer, earlier answer.
Some cancer pills are absorbed several times better with food, but the label says take them fasting at a high dose. Taking a quarter of the dose with breakfast can give the same drug levels at a quarter of the price.
Cheap copies of key antibody drugs exist but many countries cannot check their quality. A WHO quality stamp plus large pooled orders would make them safe to buy and very cheap.
AMPLIFY delivered the first all-oral, fixed-duration doublet for front-line CLL and supported its approval, giving fit patients a way to avoid both chemotherapy and years of continuous BTK inhibitor. It does not settle whether a doublet or triplet is best, or how AV compares with venetoclax-obinutuzumab. Patients with TP53 aberration were excluded and still need different strategies.
Patients with newly diagnosed metastatic colorectal cancer whose tumour carries a BRAF V600E mutation, which is about 8-12% of cases, should now be offered encorafenib and cetuximab together with FOLFOX from the start rather than after chemotherapy fails; median survival has roughly doubled to about two and a half years. BRAF testing at diagnosis is therefore essential, alongside RAS and mismatch repair testing. The regimen is more toxic than chemotherapy alone.
Patients with hormone-receptor-positive metastatic breast cancer that has stopped responding to endocrine therapy can be offered trastuzumab deruxtecan as their first chemotherapy-type treatment if the tumour shows any HER2 staining, rather than waiting until after conventional chemotherapy. Whether to use it before or after chemotherapy is now a choice, since overall survival was not shown to differ and the drug carries a risk of lung inflammation.
Almost every patient newly diagnosed with advanced bladder or urothelial cancer should now be offered enfortumab vedotin plus pembrolizumab rather than chemotherapy, with median survival extended from about 16 months to over two and a half years. Neuropathy and skin toxicity need monitoring and dose adjustment, and patients with severe diabetes or pre-existing neuropathy need care. Platinum chemotherapy remains an option for those who cannot receive the combination.
Women with locally advanced cervical cancer that is node-positive or stage III-IVA should now be offered pembrolizumab alongside and after chemoradiotherapy, which improves the chance of cure. The result matters most in countries where cervical cancer is common but immunotherapy access is poorest, so its global impact depends on pricing and health-system capacity. It does not apply to early-stage disease treated with surgery or to lower-risk locally advanced disease without nodal involvement.
Patients newly diagnosed with EGFR-mutated advanced lung cancer now have a first-line option that improves survival over osimertinib, particularly if they have high-risk features. The trade-off is intravenous (now subcutaneous) infusions and considerably more skin, nail and clotting toxicity, so osimertinib alone remains reasonable for those who prioritise convenience and tolerability. Both this regimen and osimertinib plus chemotherapy (FLAURA2) are approved; there is no direct comparison.
Ribociclib is a second adjuvant CDK4/6 option, and the only one with data in node-negative stage II disease. Roughly 3 in 100 patients avoid a relapse or death at three years, so the decision depends heavily on individual risk, tolerance of a three-year oral drug, and cost. Whether the benefit persists after treatment ends, as it did with abemaciclib, needs longer follow-up.
COMMANDS moved luspatercept from second line (after ESA failure, MEDALIST trial) to first line, offering transfusion-dependent lower-risk MDS patients a better chance of transfusion freedom from the start. It changed guidelines and labels in 2023. Erythropoietin remains a reasonable and cheaper option for patients without ring sideroblasts or with low transfusion burden.
For fit patients with newly diagnosed metastatic pancreatic cancer, a FOLFIRINOX-type regimen is now proven to be better than gemcitabine plus nab-paclitaxel, settling a long-standing debate. The absolute gain is about two months of median survival, and the regimen is more toxic for the gut. Whether liposomal irinotecan adds anything over conventional irinotecan (standard FOLFIRINOX) has never been tested head-to-head.
POLARIX gave the first new first-line standard for DLBCL since rituximab was added to CHOP, and pola-R-CHP is now approved and widely used, especially in higher-risk or ABC-type disease. The gain is modest and survival is unchanged, so many clinicians still use R-CHOP in lower-risk or GCB-type patients. Cost and subgroup uncertainty drive ongoing debate.
Every resected non-squamous lung cancer should be tested for EGFR mutations, because patients who carry one live longer if they take osimertinib for three years after surgery. The trial does not tell us whether adjuvant chemotherapy can be omitted, nor what happens on relapse after osimertinib, and the three-year duration was chosen empirically.
ELEVATE-TN put a more selective BTK inhibitor into first-line CLL and, with the head-to-head ELEVATE-RR trial, showed it is as effective as ibrutinib with fewer cardiac side effects. Continuous acalabrutinib became one of the two main front-line options alongside fixed-duration venetoclax combinations. The trade-off is indefinite therapy and cost versus a time-limited course.
Women with hormone-receptor-positive, HER2-negative breast cancer that has spread to lymph nodes and has other high-risk features can now be offered two years of abemaciclib alongside their hormone therapy, with a durable reduction in relapse. It does not apply to node-negative or low-risk disease, and the diarrhoea and cost are real trade-offs to discuss.
MAIA made a daratumumab-based triplet the standard first treatment for older or frail myeloma patients, replacing Rd alone. It proved an anti-CD38 antibody could improve survival, not just delay progression, when used up front. Quadruplets built on this backbone are now being tested in the same population.
Women with newly diagnosed advanced ovarian cancer should have their tumour tested for BRCA mutations and homologous recombination deficiency, because those who are HRD-positive gain years of additional disease control and better survival from adding olaparib to bevacizumab maintenance. Those who are HRD-negative gain nothing from olaparib in this combination and should not be exposed to its toxicity and cost. HRD testing has become a routine part of ovarian cancer care as a result.
ELIANA turned CAR-T from a single-centre experiment into a licensed product and created the regulatory and logistical template every later cell therapy has followed. For children with refractory leukaemia it offers a chance of durable remission without transplant. The trial also exposed the gaps: manufacturing failures, patients dying while waiting, and roughly half relapsing within a few years.
Men diagnosed with prostate cancer that has already spread, or that is locally advanced and high risk, should start abiraterone (or another androgen-receptor pathway inhibitor) at the same time as testosterone suppression rather than waiting for resistance. This roughly halves the risk of death over several years. The same platform later showed that docetaxel chemotherapy and, in high-volume metastatic disease, triple therapy also help, and that abiraterone benefits men with high-risk disease treated with radiotherapy.
A drug that shrinks tumours or delays progression on scans has not necessarily been shown to help patients live longer or better. Patients and clinicians should ask what the endpoint was; regulators should insist on timely confirmatory trials; and trialists should validate surrogates before relying on them.
IRIS made imatinib the first-line standard for CML worldwide and established the tyrosine kinase inhibitor as a chronic, life-long oral therapy. For most patients CML became a manageable condition with near-normal life expectancy. Later generations of TKIs (dasatinib, nilotinib, asciminib) produce faster, deeper responses but have not shown a survival advantage over imatinib.
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not linked directly; found by shared links- BottleneckIncentives reward me-too drugs and marginal gains
Shares Bundled episode payments for cancer care with bonuses for guideline concordance, Cap public prices for new cancer drugs to tiers of the ESMO and ASCO value scales, Disclose R&D and manufacturing costs of publicly funded cancer drugs to get coverage, A Health Impact Fund pilot that pays for measured health gain instead of price.
- BottleneckMost of the world has almost no cancer care
Shares A joint price negotiation bloc for middle-income countries, modelled on Beneluxa, Buy out the patent on a curative cancer drug and sell it at generic prices, Grant extra exclusivity only in exchange for binding low prices in poorer countries, A Gavi-style pooled purchaser for radiotherapy equipment and service.
- TermProgression-free survival (PFS)
Shares Provisional prices for surrogate-endpoint approvals, reset when survival data arrive, Launch prices indexed to the ESMO benefit scale, revisited when survival matures, Power trials to detect a benefit patients would value, not the smallest detectable one, Gemeinsamer Bundesausschuss / IQWiG.
- TermOverall survival (OS)
Shares Provisional prices for surrogate-endpoint approvals, reset when survival data arrive, Launch prices indexed to the ESMO benefit scale, revisited when survival matures, Pharmaceutical Benefits Advisory Committee, Power trials to detect a benefit patients would value, not the smallest detectable one.
- ProductNivolumab
Shares Automatic price cuts when a cancer drug's approved indications and volumes expand, Publicly funded trials of lower and less frequent doses of expensive cancer drugs, Restore weight-based dosing and vial sharing for immunotherapy in the label, Subscription pricing for checkpoint inhibitors: fixed national fee, unlimited use.
- BottleneckRegulatory divergence between regions
Shares One evidence plan agreed by regulator and payer before the pivotal trial, Provisional prices for surrogate-endpoint approvals, reset when survival data arrive, Approve cancer biosimilars on analytics and pharmacokinetics, no efficacy trials, WHO prequalification plus pooled demand to push biosimilar prices below 10% of the originator.
- ProductTrastuzumab
Shares Biosimilar-first defaults and payment parity in every cancer day unit, Tie WHO essential-medicines listing to a published tiered price and supply pledge, Pooled procurement and voluntary licensing for essential cancer medicines in low-income countries, Approve cancer biosimilars on analytics and pharmacokinetics, no efficacy trials.
- BottleneckWrong doses
Shares Publicly funded trials of lower and less frequent doses of expensive cancer drugs, Restore weight-based dosing and vial sharing for immunotherapy in the label, Use food effects to cut the dose and cost of oral drugs that absorb better with meals, Test flat versus weight-based dosing of antibodies, and use dose banding to cut waste.