Surgery and radiotherapy cure most, get least
Surgery and radiotherapy cure more people than drugs do, but attract a fraction of the research investment.
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.
- 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.
- NRG Oncology, EORTC, JCOG and the UK's National Radiotherapy Trials Quality Assurance group run and quality-assure multicentre radiotherapy trials.
- The IDEAL framework provides a staged methodology for evaluating surgical innovation analogous to drug phases.
- Cancer Research UK's RadNet network funds radiotherapy research centres across the UK.
- The Lancet Oncology Commissions on global cancer surgery and radiotherapy quantified the return on investment in both modalities.
- Trials such as MSLT-II, LACC, MARS 2, SANO and PROTECT have shown that testing established procedures changes practice.
- FLASH, MR-linac, proton and biology-guided radiotherapy (RefleXion) are being evaluated in academic-industry consortia.
Record cancer operations (with consent), link each video to the pathology report and the patient's recovery, and open the collection to researchers to learn what surgical technique actually works.
Ultra-fast radiotherapy may spare healthy tissue while still killing tumours, but every centre is testing it differently. A coordinated programme would agree the measurements and run the trials that settle whether it works.
For some cancers, drugs and radiotherapy can now cure without removing the organ, sparing patients a stoma, a lost voice or a removed bladder. A dedicated programme would run the trials to prove where this is safe.
Radiotherapy machines record exactly how much dose every organ received, but the data are thrown away. Collect them and link to toxicities and cures to learn the safest, most effective doses.
Radiotherapy may make immunotherapy work better, but the trials to test this are scattered and often small. One shared platform, run by radiotherapy groups with drugs supplied by several companies, would settle it faster.
Surgery cures more cancer than any drug, yet most operations have never been compared in a proper trial. A standing network of hospitals, with core funding, would run those trials continuously.
Tools that show surgeons where the tumour ends during the operation could cut the number of patients who need a second operation, but none has been properly tested at scale. A network would run those trials and pay on results.
New ways of giving radiotherapy are adopted without the staged testing that drugs go through, and are then hard to evaluate. A defined pathway with fee waivers and clear evidence steps would bring rigour without blocking progress.
Radiotherapy is given to half of all cancer patients but few new drugs are tested alongside it. A permanent trial platform would test drug-plus-radiation pairs systematically.
Surgery and radiotherapy cure more people than drugs but get a fraction of trial funding because there is no company sponsor. A rule would guarantee them a fixed share of public trial money.
New surgical tools, imaging probes and radiotherapy hardware invented in universities rarely attract investors. A dedicated fund would pay for prototyping, safety testing and first-in-human studies.
Surgeons' skill affects whether cancer comes back, but nobody measures it. Recording operations and rating them, increasingly with AI, then linking ratings to outcomes, would make surgical quality visible and improvable.
Radiation therapists, the staff who deliver daily treatment, can be trained to outline normal organs on scans and to review patients during treatment, work that oncologists now do.
Hospitals buy multi-million-dollar surgical robots and AI tools with little proof they help patients. An independent body would run the comparative trials, and payers would only pay premiums for what is shown to work.
Design a radiotherapy machine from scratch for hospitals with patchy electricity, heat and few engineers, and publish the design so several companies can build it cheaply.
Dozens of countries have no radiotherapy machine at all. Combine long-term finance with a machine designed to be cheap, robust and maintainable where power and engineers are scarce.
Ultra-fast FLASH radiotherapy and proton beams may spare healthy tissue dramatically, but the machines cost tens of millions. Engineer versions that any hospital can afford.
Radiotherapy trials need physicists to check every plan and central review of every target drawn, which nobody pays for. Fund that infrastructure permanently so trials are faster and results are trustworthy.
Radiotherapy machines that adapt to the tumour each day cost far more than standard ones and their benefit is unproven. Payers would fund them only within registries and trials that measure whether they help.
Focused ultrasound, histotripsy, heat and electric-field ablation can destroy tumours without an incision, but each maker runs its own small study. Publicly-funded trials would compare them fairly against surgery.
Almost no surgeons or radiation oncologists have time or funding to do research. Dedicated training awards with protected time would build the workforce that surgical and radiotherapy trials need.
When a geriatrician helps manage older patients around the time of a cancer operation, complications, delirium and hospital stays fall. This should be standard for anyone over 75 having major cancer surgery.
Cervical cancer cannot be cured by external radiotherapy alone; it needs internal radiation, which many hospitals lack. A cheaper internal-radiation unit using a long-lived source could be placed in every regional centre.
Giving radiotherapy in five larger doses over one week instead of 15-25 smaller doses is proven safe for breast and prostate cancer and could treat three times as many patients on the same machines.
New operations and surgical devices spread by enthusiasm, not evidence. Every new technique would have to be entered in a registry that tracks patients through defined stages before it can be widely used and paid for.
Focused ultrasound can break a tumour apart without heat or cuts, leaving debris the immune system can learn from. Doing that to one tumour may help treat the rest.
In places where sophisticated machines break down, a modern version of the older cobalt radiotherapy unit, upgraded with image guidance, could treat more people reliably while infrastructure catches up.
A few weeks of exercise, nutrition and mental preparation before a big operation helps older patients recover faster and with fewer complications. It costs little and should be routine.
Governments and donors should buy guaranteed working hours from radiotherapy vendors, with remote monitoring and regional spare-parts depots, instead of buying machines that then sit broken.
Hospitals are paid for each radiotherapy session, so a proven five-session course earns less than an unproven twenty-five-session one. Paying per course removes the reason to give more treatment than needed.
Many low-risk patients get operations and radiotherapy they may not need. Health systems would fund the trials that find out who can safely skip them, and keep the savings.
Radiation can alert the immune system, but too big a single dose destroys the very alarm signal it creates. Picking the right dose and schedule may be free extra benefit.
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.
Nobody can patent a better way of operating or a shorter radiotherapy schedule, so nobody is rewarded for proving one. Prizes for technique improvements shown to work in trials would fill that gap.
Where you have your cancer operation strongly affects whether you survive it. Publishing each hospital's adjusted results would push complex surgery towards the centres that do it well.
Half of cancer patients need radiotherapy and most of the world cannot get it. Commit to low-cost machines, automated planning and trained staff so that access is universal by 2040.
Surgeons often cannot see where a tumour ends. Fluorescent dyes and AI-read imaging in the operating theatre can show them, cutting repeat operations. Make this routine everywhere.
Pumping drugs slowly through fine tubes into a brain tumour can bypass the barrier, but the fluid often leaks away. Robotic placement and live scans would show where it actually goes.
One radiotherapy session relieves bone pain as well as ten, according to many trials, yet most patients still get the longer course. Making one session the default would spare patients trips and free machines.
Surgery cures more cancers than any other treatment, but most district hospitals refer everything to a distant centre. Train and mentor general surgeons to do common cancer operations well, with specialists checking results.
Drawing targets and planning radiotherapy takes hours of scarce expert time. Properly tested AI could do much of it, letting the same staff treat far more patients, if regulators and payers set clear rules for proving and paying for it.
Patients with high-risk bladder cancer confined to the lining whose disease has not responded to BCG now have a bladder-sparing option that clears the cancer in most cases, delivered through a simple outpatient procedure. It may allow many to avoid or defer cystectomy, a life-changing operation. Whether responses translate into avoided progression and cystectomy over the long term, and how it compares with cystectomy on survival, remain to be shown.
Patients with limited-stage small-cell lung cancer who complete chemoradiotherapy without progression should now be offered up to two years of durvalumab consolidation, which extends life by almost two years on average. This is the first survival improvement for limited-stage disease since twice-daily radiotherapy and prophylactic cranial irradiation, and small-cell lung cancer is no longer a disease where immunotherapy gives only marginal gains.
Patients with melanoma that has spread to palpable lymph nodes should now be offered immunotherapy before rather than only after surgery: two cycles of low-dose ipilimumab with nivolumab, then surgery, with the pathology result deciding whether any more treatment is needed. Most patients respond well and are spared a year of adjuvant therapy. Serious side effects are more common than with nivolumab alone, mostly endocrine, and the approach requires close coordination between oncologists, surgeons and pathologists.
For colon cancer that is mismatch-repair deficient (about 10-15% of colon cancers, more in older patients), a single short course of immunotherapy before surgery is now a reasonable standard and is far more effective than chemotherapy, which barely works in this subtype. It requires testing every colon cancer for mismatch repair at diagnosis, before surgery. Whether some patients can safely skip surgery, as in dMMR rectal cancer, is the next question.
NICHE-2 shows that a month of immunotherapy before surgery can effectively cure locally advanced dMMR colon cancer, where chemotherapy after surgery has limited benefit. It is changing guidelines towards neoadjuvant checkpoint blockade for this group and raises the question of whether surgery can be omitted altogether, as in dMMR rectal cancer. Whether the same applies to MMR-proficient tumours is being tested but is not established.
Cercek's dostarlimab study is the clearest demonstration that immunotherapy can replace surgery in a solid tumour: patients with dMMR rectal cancer can keep their rectum and avoid the permanent effects of pelvic radiotherapy and surgery. Non-operative management after PD-1 blockade is now in guidelines for this group, and MMR testing before treatment of rectal cancer is essential. The approach applies only to the 5-10% of rectal cancers that are dMMR.
Patients with rectal cancer whose tumour is mismatch-repair deficient (about 5-10% of rectal cancers) can now be offered immunotherapy alone with the realistic expectation of avoiding surgery, radiotherapy and a permanent stoma. This requires mismatch repair testing on the diagnostic biopsy, close endoscopic and MRI surveillance, and treatment in an experienced centre. It does not apply to the 90% of rectal cancers that are mismatch-repair proficient.
Patients with stage III lung cancer that cannot be removed surgically should receive a year of durvalumab after completing chemoradiotherapy, provided they have not progressed. This roughly doubles the chance of being alive without progression at five years. Whether the benefit extends to PD-L1-negative tumours is contested, and the EGFR-mutated subgroup is better served by osimertinib (LAURA).