ideasIdea
A public fund for trials that test less treatment
No company will pay to find out whether six months of its drug works as well as twelve. A dedicated public fund would pay for those trials, which save patients side effects and health systems money.
A ring-fenced fund (national research agency or philanthropic) that only supports randomised non-inferiority trials of shorter duration, lower dose, fewer cycles, omitted components or less frequent dosing of approved therapies, with a standing statistical and design core and pre-agreed non-inferiority margins co-developed with patients. Precedents: PERSEPHONE (6 vs 12 months trastuzumab), SOLD, and low-dose abiraterone; funders such as the UK NIHR HTA programme and the Anticancer Fund have supported some.
Hypothesis
Each dollar invested in de-escalation trials will return multiples in avoided treatment cost within five years of read-out, and at least a third of funded trials will change guidelines.
Rationale
The incentive gap is structural: de-escalation reduces revenue. The trials are cheap relative to the drug spend they interrogate, and several have already changed practice.
What would test it
Fund ten trials over five years and audit guideline changes, avoided drug costs and patient-reported toxicity differences against the fund's outlay.
Maturity
being tested at scale
Who has to act
philanthropy
Cost to try
Large (over $50M)
Years to first evidence
5
Bottlenecks it attacks
- Trial design, endpoints and cost · A phase 3 trial takes years and hundreds of millions of dollars, and often answers a question that has already moved on.
- Toxicity and quality of life are undervalued · Trials measure how long people live, not how they live. Side-effects are under-reported and under-treated.
- Incentives reward me-too drugs and marginal gains · 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.