Advancing Global Health Equity in Oncology Clinical Trial Access

Despite significant advancements in oncology research and treatment, cancer remains a leading cause of death and suffering, with an estimate of more than 19 million new diagnoses and 10 million cancer deaths worldwide (1). Globally, breast cancer is the most commonly diagnosed cancer, followed by lung and colorectal cancers. Lung cancer remains the leading cause of cancer death, followed by colorectal, stomach, and liver cancers (Supplementary Fig. S1). China contributes to approximately 24% of reported global cancer cases and accounts for more than 30% of global cancer deaths, representing the country with the greatest cancer burden, followed by the United States and India (Supplementary Fig. S2). However, the true incidence of cancer in low- and middle-income countries (LMIC) may significantly exceed reported cases. For instance, the actual cases in India may be substantially higher than the reported cases due to the lack of uniform cancer registries in some states. Japan, Germany, Brazil, Russia, and other countries have all reported high cancer burden, and no country is spared the scourge of cancer.

Cancer survival rates differ significantly among countries. The average 5-year survival rates globally of breast, stomach, lung, and prostate cancers for 2023 are approximately 78%, 26%, 14%, and 79%, respectively (1). The 5-year survival rates for breast cancer are 90% in the United States and 70% in Russia, and those for prostate cancer are 97% in the United States and 58% in India. In developing regions like Africa and Latin America, breast cancer survival rates may be more than 1.5 times and 1.2 times lower than those in the United States, respectively (e.g., South Africa at 53.4%, Colombia at 76%, and the United States at 90%). The significant disparities in survival across regions may be attributable to inadequate cancer screening, delays in diagnosis, and a lack of access to affordable treatments in LMICs.

Oncology research and development (R&D) through clinical trials remain the critical step of translating scientific discoveries into lifesaving interventions and treatments through regulatory approvals. Funding for oncology R&D is now increasingly driven by the pharmaceutical industry, which continues to invest heavily in major oncology indications, outpacing other therapeutic areas (Fig. 1A). We estimated that the global industry investment for oncology R&D through clinical trials has exponentially grown to more than US$80 billion annually, which has far surpassed the annual spending of the U.S. NCI at US$6.8 billion in 2022, reflecting the changing global trends and landscape over the past two decades. Our estimation was triangulated across three different top-down and bottom-up approaches, leveraging data sources such as publicly available annual R&D spending reports and clinical trials posting, and making assumptions on the average clinical trial cost per patient per therapeutic area. The oncology pipeline also continues to expand, with more than 2,500 unique clinical-stage assets, which is approximately five times greater than other therapeutic area pipelines (Fig. 1A). As the cost per patient also increases, the overall clinical trial spending has a higher growth rate compared with the growth of the number of assets. R&D spending can be further broken down by international and domestic trials. Currently, more than 70% of clinical trials are conducted in a single country, whereas 24% of trials are conducted across multiple countries or at least with one other country (Fig. 1B). Despite the heavy investment in oncology R&D and the universal recognition by international academic societies and guidelines that clinical trials represent an innovative treatment to improve the care of patients with cancer, patient enrollment in clinical trials remains abysmally low at fewer than 5% globally. Consequently, the R&D timeline from laboratory discovery to regulatory approval of new treatments and prevention is excessively protracted and can take more than 10 years.

Pipeline growth is driving increased competition for patients, especially in competitive indications. Globally, the number of patients required for active global clinical trials has increased, with a compound annual growth rate of 7% on average over the past 5 years (Fig. 1C). Among major oncology indications, trials of lung and breast cancers have a higher number of patient recruitment targets. Colorectal cancer and multiple myeloma have the highest growth rates (compound annual growth rates of 11% and 25%, respectively). Despite the high demand for patients, clinical trial participation rates remain low, with a global average below 5%. This has slightly improved in the United States at 7.1% according to recent data from the Commission on Cancer (2). By dividing the patient numbers required for clinical trials by the cancer incidence numbers, the clinical trial participation rates were estimated for all major oncology indications. Pancreatic cancer has the highest rate at 11%, and prostate and colorectal cancers have the lowest rates at 0.7% and 0.6%, respectively. The lower rates of clinical trial participation in patients with prostate cancers is partially driven by the fact that many of them are diagnosed early and well-managed with standard therapy; thus, they are either not eligible or unwilling to participate in clinical trials. Conversely, patients with pancreatic cancer are often diagnosed at advanced stages, and with limited treatment options, more patients are eligible and inclined to participate in clinical trials. Interest in clinical trial participation is increasing, with more than 50% of patients expressing a willingness to participate if given the opportunity (2). However, various barriers including patient, clinician, trial site/healthcare system, industry, and regulatory factors continue to create an impediment to the enrollment of eligible patients in clinical trials.

The development of innovative oncology therapies and products is dependent on the successful implementation of clinical trials. There are numerous barriers across multiple stakeholders that exist across the oncology R&D ecosystem.

Patient participation is crucial to the success of clinical trials; however it continues to be limited because of several factors, of which the principal factor is a lack of awareness and education about clinical trials. Studies suggest that public knowledge of clinical trials is scarce, with an estimated 85% of patients unaware of clinical trial options at the time of their diagnoses. More than 50% of patients indicated that they would participate in a clinical trial if their doctor had informed them about the opportunity (3). Specifically for oncology trials in the United States, 32% of adults would be “very willing” to participate and an additional 28% of adults would “consider” participating in a clinical trial if they were aware of the opportunity (3, 4).

Another challenge arises from geographical disparities in the location of trial sites in healthcare systems, many of which are concentrated in urban areas, posing accessibility issues for potential participants living in rural regions. In a 2021 study, rural participants traveled 35 miles further than their urban peers to reach a clinical trial site (4). This increased travel time could translate to increased financial strain related to travel expenses and time off work, as well as the physical toll of traveling with illness. Even within relatively localized areas, the time, frequency, and logistics involved in traveling to clinical trial sites for screening, follow-ups, and routine monitoring can be significant deterrents.

Racial and ethnic disparities in clinical trials are another area of concern, with evidence suggesting that minority groups are substantially underrepresented in these studies (5). In the United States, although racial–ethnic minority participation has modestly increased over the years, there is still an urgent need for vast improvement, especially for the Black and Hispanic populations. Systemic hurdles, such as the lack of accessible trial sites in many communities, healthcare insurance coverage, language barriers, and the prohibitive costs of travel and time, further compound these disparities by geographic and socioeconomic statuses (5).

On the clinician, clinical trial site, and healthcare system front, the technical requirements are high, and challenges are diverse. Clinicians often grapple with time constraints and capacity issues, especially when dealing with complex and multimodal trial protocols. In addition, the high attrition rates and the scarcity of specialized study coordinators make it difficult to ensure the retention of skilled support staff essential for trial continuity and success (4). Clinical trial personnel have especially become more constrained in recent years, driven by wage stagnation, burnout and job dissatisfaction, and the rising cost of living (6). We are seeing increasing resignation rates of approximately 3% across healthcare systems, with the most likely group of healthcare workers to participate in the Great Resignation being those with more than 10 years of work experience (6). Furthermore, the COVID-19 pandemic caused a significant disruption in the clinical pipeline, driven by work-from-home requirements; the delays thus led to an unusually higher number of clinical trials awaiting activation. For example, the United Kingdom saw a 52% increase in the number of clinical trial projects between 2019 and 2021 (7). An increase in pending clinical trials combined with more experienced healthcare workers leaving for new jobs or earlier retirement driven by persistent staff burnout led to significant human resource constraints for oncology studies. In addition to the challenges above, clinical trials in LMICs also suffer from a lack of experienced sites, fewer available sponsor and contract research organization staff for site monitoring, and limited equipment available for prompt assessment of study endpoints (5, 8).

There exists a stark disparity in clinical trial distribution between high-income countries (HIC) and LMICs. For instance, although Africa accounts for roughly 15% of the global population and bears 25% of the worldwide disease burden, only an estimated fewer than 2% of global oncology clinical trials are conducted in Africa (9, 10). Unlike HICs such as the United States, LMICs face challenges such as limited funding for clinical trials and delays in regulatory and ethical reviews. The clinical trial activation approval timeline from government regulators and institutions can be months to years rather than weeks. This delay can be partially explained by less mature regulatory systems, less standardized institutional review boards and ethics committee set-up, fewer staff, and limited experience in clinical trials. Delayed regulatory processes negatively impact the funding approval for clinical trials. For some LMICs countries, such as Ethiopia, it is not uncommon for clinical trial grants and funding to expire while waiting for regulatory approval (9). As we have previously argued, the lack of global regulatory harmonization is one of the greatest barriers to the development of novel cancer treatments and prevention worldwide (3, 11).

Clinical trial enrollment faces additional barriers beyond patient, clinician, site, and regulatory factors, such as limited community site access to more experienced trial centers, insufficient infrastructure support, poor-quality data collection and management, outdated protocol design with excessive exclusion criteria, and the relative lack of public trust on pharmaceutical clinical trials. Therefore, the multifaceted challenges that hamper the access to and success of oncology clinical trials require global, comprehensive, collaborative, and inclusive solutions to ensure that the vast potential of diverse global communities is fully realized and benefits all sections of society.

Although there is no single definitive solution to the complex problems of oncology clinical trials; several strategies can be used to mitigate these challenges, enhance trial accessibility, ensure effective return on R&D investment, and accelerate clinical trial timelines. This section presents an array of potential solutions that, if implemented collaboratively, could lead to global ecosystem paradigm change.

Increasing patient access to clinical trial sites can dramatically improve participation. Clinical site access is a current problem in both HICs and LMICs. Most clinical trials occur at academic medical centers (AMC), which are predominately in urban areas. However, only about 16% of all patients currently seek care in AMCs in the United States (12). The percentage may be even less globally, especially in LMICs, which have a much lower concentration of AMCs with a lower percentage of patients who have access to clinical trials. Clinical trial access can be improved in both HICs and LMICs by implementing a “hub-and-spoke” network model. AMCs in large cities may serve as the hubs of the trial, whereas surrounding community hospitals and clinics in smaller towns and rural areas operate as the spokes. In this new network model, AMCs help community hospitals and clinics set up clinical trials by offering expertise and experience, and through remote technologies and collaboration, patients in rural areas can participate in clinical trials without frequently needing to travel long distances. Technologies such as remote monitoring, electronic data capture (EDC) and patient questionnaires, and home-based phlebotomy and s.c. injections are enabling patient-centric care at or close to patients’ homes (3). Although most clinical trials are unlikely to be fully remote, there is increased industry investment in adopting these technologies and features for a substantial portion of treatment and monitoring to be done close to patients’ homes or local communities (8). For trials that can only be done in the AMC setting, AMCs can share the latest available clinical trials as well as trial details, eligibility criteria, and recruitment materials with community hospitals and clinics on a regular basis to expand access. Community hospitals and clinics can leverage the materials to educate rural patients about the benefits of participating in clinical trials to improve overall awareness. At the same time, community hospitals and clinics can help identify eligible and willing patients and refer them to AMCs to participate in clinical trials. Such a collaboration model may be enabled by patient navigators who act as a conduit between clinicians in many sites and on behalf of the patients with the goal of facilitating clinical trial access. This hub-and-spoke model powered by technology and collaboration offers multiple advantages, including increasing awareness of clinical trials and increasing access to patients in remote and rural communities, with reduced financial and travel burden on patients by offering care close to patients’ homes. Real-world data may enable research on cancer outcomes across metropolitan and rural areas to further guide interventions to close the gap in cancer care.

Implementing a master protocol as the trial design, increasing the use of innovative technologies such as digital pathology and liquid biopsy for patient selection and trial monitoring, and digitally enhanced EDC with cloud-based data sharing may streamline clinical trial patient selection, recruitment, and operations with reduced costs.

A master protocol is a comprehensive framework that enables researchers to test multiple treatments and diagnostic approaches simultaneously. This enables resource optimization across patients, funding, and health care professionals, which allows for reduced costs and faster completion times. Master protocols also enhance statistical power and efficiency by sharing the control group across multiple substudies and allow for the correct incorporation of biomarker-driven groups (13). Patient-centric trials must start at protocol conception and design, including efforts by investigators and biopharmaceutical industry sponsors to simplify inclusion and exclusion criteria that prevent patient enrollment (3).

Previously, a tumor tissue biopsy was the standard procedure for both early- and late-stage diagnoses. Although tissue biopsies are still the standard of care, liquid biopsies for plasma ctDNA and other genetic materials are seeing an increased demand as a noninvasive method for molecular profiling of cancers in many circumstances. Where applicable, liquid biopsies can be used to screen for and diagnose cancer and analyze a patient’s biomarkers to determine if patients are suitable for precision medicines and clinical trials without invasive tissue sampling procedures and with faster turnaround times (14). Liquid biopsies can also monitor patients’ treatment processes through repeated noninvasive blood sampling. Additionally, liquid biopsies can be performed in a wider range of health care facilities, including nonhospital centers in community settings or in patients’ homes (8). This leapfrog technology may significantly help build capacity and R&D infrastructure in LMICs as well as diverse communities in HICs outside of AMCs through the hub-and-spoke model.

Data collection is at the core of a clinical study and can have significant impact on cost and efficiency. Currently, electronic medical records (EMR) are utilized for data tracking, and EDC is used for collecting data in clinical trials. However, the transfer from EMRs to EDC has not been fully automated and still requires extensive manual transcribing of data that already exist in EMRs. This multistep procedure increases cost, time, and transcribing errors. Advances in artificial intelligence technology, including trained natural language processing algorithms, are already enabling automated annotation of data directly captured from EMRs, which may be transferred to EDC for research analysis (15). Such technology will significantly reduce efforts, minimize redundancy and errors, and lower the overall cost, which is beneficial foe increasingly multisite, data-intensive oncology trials. Whereas natural language processing algorithm training requires substantial real-world data sets, increased cloud-based secure digital data sharing may usher a future of a universal EMR that may connect diverse de-identified patient data across sites and countries to accelerate discoveries and breakthroughs.

In the context of clinical trials, LMICs face many similar barriers to HICs but to a more significant degree across several factors, such as low clinical trial awareness and education, clinical trials only occurring in urban areas at AMCs, and health care professional staffing shortages. Additionally, there are much fewer clinical trials to begin with. As of June 2023, approximately 90% of all clinical trials occur in HICs and upper-middle–income countries, including the United States, Canada, Japan, Australia, China, and all of Europe (10).

However, many LMICs have substantial experience with successful clinical trial enrollment in the setting of infectious disease outbreaks which may be leveraged for oncology trials. Africa, for example, has made significant strides in building infectious disease infrastructure, including sites that can be leveraged to facilitate oncology clinical trials at relatively low costs. At the same time, the research network can serve as a foundation for collaboration between local researchers, international organizations, and pharmaceutical companies that can foster partnerships to promote clinical trial activities. Such industry investment with sponsored clinical trial funding may significantly alleviate the increasing financial burdens in the public health system. Research coordinators and navigators funded by such investment may play a crucial role in identifying and matching patients to appropriate clinical trials, particularly as the clinical workload of oncologists in LMICs can be overwhelming due to the high volume of patients they must see each day.

LMICs can also learn from their success in managing infectious diseases such as HIV to enhance regulatory frameworks and processes for clinical trials. This includes streamlining ethics review processes, ensuring participant safety, and facilitating efficient approval mechanisms.

Drawing on their experiences with community engagement during infectious disease outbreaks, LMIC community leaders, healthcare providers, and local stakeholders can be actively involved to educate people on clinical trials, foster trust, and address potential concerns about participating in trials. Through collaboration and investment in capacity building by leveraging experiences from other therapeutic areas, such as infectious diseases, LMICs may become the future engine of global oncology R&D.

These potential solutions highlight the need for a multipronged, collaborative, and concerted global effort to overcome the barriers facing oncology clinical trials. The future of oncology hinges on the sustainable execution and accessibility of these trials, and as such, building global capacity for oncology R&D should be a top priority for all stakeholders, which is the requirement for international regulatory harmonization that may save millions of lives every year (11). Through global ecosystem transformation, an oncology R&D timeline of 2 to 3 years may no longer be the exception but the norm in the future (3, 8).

Clinical trials remain the critical step of translating scientific innovation to regulatory approvals, and expanding clinical trial access is a key factor in accelerating the timeline of oncology R&D in bringing innovative therapies to commercialization to benefit millions of patients. The current global patient access to clinical trials at below 5% is both unacceptably inequitable and unsustainable for oncology R&D. Barriers to accessing clinical trials exist in both LMICs and HICs, including patient-, clinician-, healthcare system–, industry-, regulatory-, and global ecosystem–level factors. Solutions exist, including our proposed “hub-and-spoke” network model for international clinical trials, infrastructure building, optimizing the trial design with master protocols tailored to precision oncology, increasing education and awareness about clinical trials in communities, and encouraging industry investments in LMICs as the potential future engine of oncology R&D. Global ecosystem transformation through clinical trial capacity building would pave the way for international regulatory harmonization. Although clinical trial access does not have a single solution, implementing these proposed solutions through multistakeholder collaboration can significantly advance global health equity in improving access for all patients across geographical, gender, racial–ethnic, and socioeconomic groups, which will collectively accelerate the “Cure4Cancer” movement in this lifetime, ultimately ending cancer as a major cause of death.

The authors have not received any financial compensation for this publication. The authors at Memorial Sloan Kettering Cancer Center are supported by the Cancer Center Support Grant P30 CA008748 from the NIH. B. Daly reported receiving personal fees from Varian Medical Systems during the conduct of the study and being a cofounder of the Bloomberg New Economy International Cancer Coalition (unpaid). B.T. Li has served as an uncompensated advisor and consultant to Amgen, AstraZeneca, Boehringer Ingelheim, Bolt Biotherapeutics, Daiichi Sankyo, Genentech, and Lilly. He has received research grants to his institution from Amgen, AstraZeneca, Bolt Biotherapeutics, Daiichi Sankyo, Genentech, Jiangsu Hengrui Pharmaceuticals, Lilly, Nuvalent, and Revolution Medicines. He has received academic travel support from Amgen. He is an inventor on three institutional patents at Memorial Sloan Kettering (US62/685057, US62/514661, and US63/424813) and has intellectual property rights as a book author at Karger Publishers and Shanghai Jiao Tong University Press. He is also a senior fellow on global health for the Asia Society Policy Institute (unpaid) and a cofounder of the Bloomberg New Economy International Cancer Coalition (unpaid). C.H. dos Anjos receives speaker fees and/or honoraria for consulting or advisory functions for Daiichi Sankyo, Gilead, AstraZeneca, Novartis, and MSD. He also obtained financial support for educational programs and symposia from AstraZeneca, Daiichi Sankyo, MSD, Lilly, Rcohe, Novartis, Gilead, and Medscape. C.M. Rudin has consulted about oncology drug development with AbbVie, Amgen, D2G, Jazz, Mariana, Scorpion, and Treeline. He serves on the scientific advisory boards of Auron, Bridge Medicines, DISCO, Earli, and Harpoon Therapeutics. D.R. Jones serves on the advisory council for AstraZeneca and receives research grant support from Merck. G. Abou-Alfa reports receiving grant and research support from Arcus, AstraZeneca, BioNtech, Bristol Myers Squibb, Celgene, Flatiron, Genentech/Roche, Genoscience, Incyte, Polaris, Puma, QED, Silenseed, and Yiviva and consultant fees from Adicet, Alnylam, AstraZeneca, Autem, BeiGene, Berry Genomics, Boehringer Ingelheim, Celgene, Cend, CytomX, Eisai, Eli Lilly, Exelixis, Flatiron, Genentech/Roche, Genoscience, Helio, Helsinn, Incyte, Ipsen, Merck, Nerviano, Newbridge, Novartis, QED, Redhill, Rafael, Servier, Silenseed, Sobi, Vector, and Yiviva. G. Abou-Alfa also reports filed patent PCT/US2014/031545, filed: March 24, 2014, and priority application Serial No.: 61/804907, filed: March 25, 2013. G. Rocco has financial relationships with Medtronic, Merck, AstraZeneca, CEEVRA, and Scanlan International. H.-Y. Tu reported receiving speaker fees from AstraZeneca, Bristol Myers Squibb, Pfizer, Boehringer Ingelheim, Merck, and Roche. J.A. Drebin reported having equity shares from Ionis Pharmaceuticals, Arrowhead Pharmaceuticals, and Alnylam outside the submitted work and having an immediate family member employed in a leadership role at American Regent. J.M. Isbell reports Consulting/Advisory Board/Steering Committee Membership for AstraZeneca, Merck, and prAna and equity ownership from LumaCyte, LLC. He also received institutional research support from AstraZeneca, Guardant Health, and Foresight Diagnostics. J. Mills is an employee of Foundation Medicine, Inc., and has equity in Roche, Merck, Abbott, and Abbvie. J. Qian has received institutional grants from AstraZeneca, Amgen, BeiGene, and Boehringer Ingelheim. J. Reis-Filho reports current employment at AstraZeneca and stocks in AstraZeneca, Repare Therapeutics, and Paige.AI; J. Reis-Filho previously held a fiduciary role in Grupo Oncoclinicas and was a consultant with Goldman Sachs Merchant Banking, Bain Capital, Repare Therapeutics, Paige.AI, Volition Rx, and MultiplexDx. L. Diaz divested his equity in Personal Genome Diagnostics to LabCorp in February 2022 and divested his equity in Thrive Earlier Detection to Exact Biosciences in January 2021. L.A. Diaz’s spouse holds equity in Amgen. L. Norton reports support from Agenus Inc., Celgene Cold Spring Harbor Laboratory, QLS Advisors LLC (professional services/activities), American Society of Clinical Oncology, Breast Cancer Research Foundation, NewStem Ltd., Springer Nature Limited, Translational Breast Cancer Research Consortium, and the U.S. Department of Justice (professional services and activities, uncompensated). N. Pavlakis has received honoraria from Boehringer Ingelheim, Merck Sharp & Dohme, Merck, Bristol Myers Squibb, AstraZeneca, Takeda, Pfizer, Roche, Novartis, Ipsen, and Bayer and research funding from Bayer, Pfizer, and Roche. S.P.S. holds equity in Canesia Health, Inc. O.I. Olopade reported being cofounder of CancerIQ and receiving other support from Tempus SAB and grants from Color Genomics Research Support and Roche/Genentech outside the submitted work. P. Razavi has received research funding from GRAIL, Illumina, Novartis, Epic Sciences, and ArcherDx and served as a consultant for Novartis, Foundation Medicine, AstraZeneca, Epic Sciences, Inivata, Natera, and Tempus. Q. Zhou reports honoraria from AstraZeneca, Lilly, Roche, Pfizer, Boehringer Ingelheim, MSD Oncology, Bristol Myers Squibb, and Hengrui. S. McBride served as consulting or advisory role for Janssen and AstraZeneca. He also received research funding from Genentech and AstraZeneca. S. Mondaca serves in a consulting or advisory role for Foundation Medicine S. Clarke received advisory board and speaking remuneration from AstraZeneca. T. Haddad has received research grant funding from Takeda Oncology (Institutional) and served on an advisory board for Puma Biotechnology (no personal compensation). V. Makker reports research funding (institution) from AstraZeneca, Bayer, Bristol Myers Squibb, Clovis Oncology, Duality, Eisai Co., Ltd., Faeth Therapeutics, Karyopharm Therapeutics, Lilly, MSD, Takeda, and Zymeworks; V. Makker serves an unpaid consulting or advisory role for ArQule, AstraZeneca, Clovis Oncology, Duality, Eisai Co., Ltd., Faeth Therapeutics, GlaxoSmithKline, IBM, Immunocore, ITeos Therapeutics, Kartos Therapeutics, Karyopharm Therapeutics, Lilly, MSD, Moreo, Morphosys, Novartis, Takeda, and Zymeworks and receives support for travel, accommodations, and/or expenses from Eisai Co., Ltd. and MSD. Y.-L. Wu reports honoraria from AstraZeneca, Lilly, Roche, Pfizer, Boehringer Ingelheim, MSD Oncology, Bristol Myers Squibb, and Hengrui; Y.-L. Wu serves a consulting or advisory role for AstraZeneca, Roche, Boehringer Ingelheim, and Takeda and reports research funding from Boehringer Ingelheim, Roche, Pfizer, and Bristol Myers Squibb. A. Ene-Obong is an employee of Syndicate Bio. A. Silverstein, B. Albrecht, D. Li, H. Keane, J. Shen, M. Wilson, and P. Pilarski are employees of McKinsey & Company. B. Yoon and I-F. Chang are employees of Amgen and own stock/equity in the company. C. Kalidas and S. Oelrich are employees of Bayer AG and own stock/equity in the company. C. Tendler is an employee of Johnson & Johnson and owns stock/equity in the company. D. Fredrickson and S. Galbraith are employees of AstraZeneca and own stock/equity in the company. J. Finnegan and S. Shokrpour are employees of Bloomberg New Economy, Bloomberg L.P. J. Legos is an employee of Novartis. J.V. Oyler and M. Lanasa are employees of BeiGene. J.Yan is an employee of Zai Lab. Karen Kaucic is an employee of PPD, Thermo Fisher Scientific. L. Zhang is an employee of Jiangsu Hengrui Pharmaceuticals. M. Dickler is an employee of Genentech and owns stock/equity in the company. T. Conneran received grant support from Agilent, Amgen, Arvinas, Astra Zenneca, Bayer, Boeheringer Ingelheim, Bristol Myers Squibb, Diaceutics, Frontier Medicines, Jansen, Jaguar Health, LabCorp, Loxo@Lilly, Merck, Mirati, Novartis, Pfizer, Qiagen, Revolution Medicines, Roche, Sanofi, Verastem, and 23&Me. No disclosures were reported by the other authors.

Authors’ names according to groups in byline: Authors are listed by alphabetical order of last name and only listed once. Those listed in the first byline group will not appear in subsequent groups even if associated. Affiliations and countries are detailed in Supplementary Table S1. Bloomberg New Economy International Cancer Coalition: Tolulope Adewole, Bjorn Albrecht, Shaalan Beg, Otis Brawley, I-Fen Chang, Bobby Daly, Angelo de Claro, Jennifer Dent, Maura Dickler, Abasi Ene-Obong, Lola Fashoyin-Aje, Justin Finnegan, Susan Galbraith, Mary Gospodarowicz, Julie Gralow, Tufia Haddad, Chitkala Kalidas, Artur Katz, Karen Kaucic, Harriet Keane, Mark Lanasa, Jeff Legos, Bob T. Li, Jennifer Mills, Stefan Oelrich, Olufunmilayo I. Olopade, John Palma, Richard Pazdur, Piotr Pilarski, Jing Qian, Kevin Rudd, Sepideh Shokrpour, Craig Tendler, Matt Wilson, Victoria W. Smart, Yi-Long Wu, James Yan, and Lianshan Zhang. McKinsey Cancer Center: Diya Li, Johanna Shen, and Amy Silverstein. Cure4Cancer: Ghassan Abou-Alfa, Shelly Anderson, Patrick Beyrer, Danielle Carnival, Stephen Clarke, Terri Conneran, Lisa M. DeAngelis, Connie Diakos, Luis Diaz, Carlos Henrique dos Anjos, Jeffrey A. Drebin, Debra Eisenmen, Russell Flannery, David Fredrickson, James M. Isbell, David R. Jones, Adedayo Joseph, Caroline Kennedy, T. Peter Kingham, Adrian Lee, Nancy Y. Lee, Lillian Leigh, Zhi-Zhong Li, An-Wen Liu, Dazhi Liu, Si-Yang Liu, Si-Yang Maggie Liu, Vicky Makker, Meritxell Mallafre-Larrosa, Sean McBride, Isabel Mestres, Sebastian Mondaca, Paulo Nigro, Larry Norton, John V. Oyler, Nick Pavlakis, Simon Powell, Bruce Robinson, Yi Qin, Pedram Razavi, Jorge Reis-Filho, Gaetano Rocco, Charles M. Rudin, Orville Schell, Howard I. Scher, Deborah Schrag, Greg Simon, Dorrance Smith, Morgan Speece, Hai-Yan Tu, Aminu Umar-Sadiq, Bu-Hai Wang, Helen Wheeler, Chong-Rui Xu, Li-Xu Yan, Fan Yang, Byeong Yoon, Catharine Young, Jia-Tao Zhang, and Qing Zhou.