What Really Matters for Cancer Care – Health Systems Strengthening or Technological Innovation?

Abstract

Modern medicine has long been characterised by a relentless focus on innovation and the expansion of biomedical and scientific boundaries, with cancer at the vanguard. The more recent advent of precision medicine has pushed boundaries even further, with genomic advances allowing us to decipher the innate biology of a cancer and expand the repertoire of targets amenable to systemic therapies. However, this ‘pharmaceuticalisation of cancer care’ [[1]Abraham J. Pharmaceuticalization of society in context: theoretical, empirical and health dimensions.Sociology. 2010; 44: 603-622Crossref Scopus (238) Google Scholar] risks being highly reductionist in our pursuit of improving outcomes, pivoting research and public sentiment away from the evidence-based reality that early diagnosis as well as high-quality surgery and radiotherapy underpin better cancer outcomes for populations. The new generation of precision cancer medicines, especially immuno-oncology, are expected to contribute to 70% of the total cost of active care by 2025 [[2]Polite B.N. Ratain M.J. Lichter A.S. Oncology’s “hockey stick” moment for the cost of cancer drugs—the climate is about to change.JAMA Oncol. 2021; 7: 25-26Crossref PubMed Scopus (6) Google Scholar], whereas at the same time nearly 50% of the global population has little or no access to diagnostics [[3]Fleming K.A. Horton S. Wilson M.L. Atun R. DeStigter K. Flanigan J. et al.The Lancet Commission on diagnostics: transforming access to diagnostics.Lancet. 2021; 398: 1997-2050Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar] or palliative care, and up to 80% have no access to timely, safe and affordable surgery and radiotherapy, let alone basic generic chemotherapy [[4]Atun R. Jaffray D.A. Barton M.B. Bray F. Baumann M. Vikram B. et al.Expanding global access to radiotherapy.Lancet Oncol. 2015; 16: 1153-1186Abstract Full Text Full Text PDF PubMed Scopus (495) Google Scholar,[5]Sullivan R. Alatise O.I. Anderson B.O. Audisio R. Autier P. Aggarwal A. et al.Global cancer surgery: delivering safe, affordable, and timely cancer surgery.Lancet Oncol. 2015; 16: 1193-1224Abstract Full Text Full Text PDF PubMed Scopus (319) Google Scholar].An emphasis on precision medicine also risks reinforcing the notion that achieving the best patient outcomes can be simply addressed by ensuring cutting edge technologies are available [[6]The Lancet 20 years of precision medicine in oncology.Lancet. 2021; 397: 1781Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar], ignoring the wider social and economic contexts within which people live and that will ultimately influence their outcomes [[7]Marmot M. Social determinants of health inequalities.Lancet. 2005; 365: 1099-1104Abstract Full Text Full Text PDF PubMed Scopus (2759) Google Scholar,[8]Mialon M. An overview of the commercial determinants of health.Glob Health. 2020; 16: 74Crossref PubMed Scopus (49) Google Scholar]. Accumulating evidence shows that novel treatments tend to deliver value at the margins at best and do not contribute significantly to cancer mortality reduction at the population level [[9]Schnog J.B. Samson M.J. Gans R.O.B. Duits A.J. An urgent call to raise the bar in oncology.Br J Cancer. 2021; 125: 1477-1485Crossref PubMed Scopus (12) Google Scholar]. Investing more in biomedical research and technologies alone is therefore unlikely to result in progress in cancer survival globally without addressing the health system barriers to optimum cancer care delivery [[10]IARC Scientific Publications.in: Vaccarella S. Lortet-Tieulent J. Saracci R. Conway D.I. Straif K. Wild C.P. Reducing social inequalities in cancer: evidence and priorities for research. International Agency for Research on Cancer © International Agency for Research on Cancer, Lyon2019Google Scholar,[11]Sung H. Ferlay J. Siegel R.L. Laversanne M. Soerjomataram I. Jemal A. et al.Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.CA Cancer J Clin. 2021; 71: 209-249Crossref PubMed Scopus (17778) Google Scholar].It is health systems that fund, organise and deliver cancer care and the wider political, economic and societal context within which they are embedded that define the accessibility, affordability, equity and outcomes of cancer control interventions [[12]Morris M. Landon S. Reguilon I. Butler J. McKee M. Nolte E. Understanding the link between health systems and cancer survival: a novel methodological approach using a system-level conceptual model.J Cancer Policy. 2020; 25: 100233Crossref Scopus (9) Google Scholar,[13]Atun R. Moore G. Building a high-value health system. Oxford University Press, New York2021Crossref Scopus (3) Google Scholar]. Both of these aspects set the parameters for policies and strategies that help protect people's health (e.g. legislation on unhealthy commodities), define options for early detection and prevention (e.g. human papillomavirus vaccination), when and how people seek care, what treatments are available, who gets these treatments, the cost and cost-effectiveness of the treatment and the quality of care delivered. It also frames the science that is being produced by defining research ecosystems and prioritisation of what it is believed will drive through the greatest improvements in outcomes [[14]Moher D. Glasziou P. Chalmers I. Nasser M. Bossuyt P.M.M. Korevaar D.A. et al.Increasing value and reducing waste in biomedical research: who's listening?.Lancet. 2016; 387: 1573-1586Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar].Health systems, and the cancer services and systems within them, are complex, as highlighted in Figure 1. To address the myriad of factors that ultimately influence patient outcomes at the individual and population level we need a more balanced research portfolio that prioritises health systems research. This would enable a much deeper understanding of the multiple factors acting at different levels, their interconnections and the priorities, agency and power of the various actors within and across systems that influence cancer outcomes [[10]IARC Scientific Publications.in: Vaccarella S. Lortet-Tieulent J. Saracci R. Conway D.I. Straif K. Wild C.P. Reducing social inequalities in cancer: evidence and priorities for research. International Agency for Research on Cancer © International Agency for Research on Cancer, Lyon2019Google Scholar]. This requires bringing together a wide range of scientific disciplines, from political science to applied health services research, implementation science to epidemiology, geography to economics and anthropology to behavioural psychology.However, most cancer research funders do not consider these domains a priority for funding, potentially because the impact that investment in cancer systems and policy research would have at a national and international level is not immediately visible to clinical and patient communities. By way of introduction, we consider five major health system themes that exemplify the results of a strategic imbalance in funding and policy, and how investment could serve to address this imbalance, which is leading to a devaluation of global cancer care due to a focus on marginal gains.FinanceCancer is one of the most expensive disease domains, both from a direct healthcare costs perspective (e.g. treatments) and the indirect impact on patients and families (e.g. out of pocket expenditures) [[15]Sullivan R. Peppercorn J. Sikora K. Zalcberg J. Meropol N.J. Amir E. et al.Delivering affordable cancer care in high-income countries.Lancet Oncol. 2011; 12: 933-980Abstract Full Text Full Text PDF PubMed Scopus (526) Google Scholar,[16]Schlueter M. Chan K. Lasry R. Price M. The cost of cancer – a comparative analysis of the direct medical costs of cancer and other major chronic diseases in Europe.PLoS One. 2020; 15e0241354Crossref PubMed Scopus (8) Google Scholar]. Balanced against this is the reality that premature mortality and morbidity due to cancer is a growing burden on economies due to productivity losses [[17]Luengo-Fernandez R. Leal J. Gray A. Sullivan R. Economic burden of cancer across the European Union: a population-based cost analysis.Lancet Oncol. 2013; 14: 1165-1174Abstract Full Text Full Text PDF PubMed Scopus (585) Google Scholar]. All countries have, in principle at least, signed up to universal health coverage, where one of the key vectors is to reduce the out of pocket expenditure for care [[18]Chatham House ReportShared responsibilities for health: a coherent global framework for health financing.2014https://www.chathamhouse.org/2014/05/shared-responsibilities-health-coherent-global-framework-health-financingGoogle Scholar]. However, for many countries, particularly in the low-middle income countries (LMIC) category, the political decision to allocate less than the mandatory 5% of general government expenditure to health and the failure to develop either social insurance protection models have in essence condemned over a billion people to catastrophic impoverishing expenditures if they receive a diagnosis of cancer. One of the most critical policy changes is the need for the cancer community to advocate for a minimum GDP expenditure on public health care. Without this, any notion of progress for global cancer outcomes is doomed to failure. This impact falls disproportionally on the most deprived sectors of society.Even for those notionally able to pay, the risk of financial toxicity due to rising out of pocket treatment costs continues to increase in most countries [19Carrera P.M. Kantarjian H.M. Blinder V.S. The financial burden and distress of patients with cancer: understanding and stepping-up action on the financial toxicity of cancer treatment.CA Cancer J Clin. 2018; 68: 153-165Crossref PubMed Scopus (331) Google Scholar, 20Boby J.M. Rajappa S. Mathew A. Financial toxicity in cancer care in India: a systematic review.Lancet Oncol. 2021; 22: e541-e549Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 21Perrone F. Jommi C. Di Maio M. Gimigliano A. Gridelli C. Pignata S. et al.The association of financial difficulties with clinical outcomes in cancer patients: secondary analysis of 16 academic prospective clinical trials conducted in Italy.Ann Oncol. 2016; 27: 2224-2229Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 22Honda K. Gyawali B. Ando M. Kumanishi R. Kato K. Sugiyama K. et al.Prospective survey of financial toxicity measured by the comprehensive score for financial toxicity in Japanese patients with cancer.J Glob Oncol. 2019; 5: 1-8PubMed Google Scholar, 23Bygrave A. Whittaker K. Paul C. Fradgley E.A. Varlow M. Aranda S. Australian experiences of out-of-pocket costs and financial burden following a cancer diagnosis: a systematic review.Int J Environ Res Public Health. 2021; 18: 2422Crossref PubMed Scopus (7) Google Scholar]. From privatised cancer systems such as the USA, socialised systems such as Italy, to LMICs such as Kenya, out of pocket expenditure is one of the most serious issues holding back progressive universalism. In the USA, some 50% of cancer survivors experienced financial distress associated with their cancer [[24]Altice C.K. Banegas M.P. Tucker-Seeley R.D. Yabroff K.R. Financial hardships experienced by cancer survivors: a systematic review.J Natl Cancer Inst. 2016; 109: djw205Crossref PubMed Scopus (358) Google Scholar,[25]Yabroff K.R. Zhao J. Zheng Z. Rai A. Han X. Medical financial hardship among cancer survivors in the United States: what do we know? What do we need to know?.Cancer Epidemiol Biomarkers Prevent. 2018; 27: 1389-1397Crossref PubMed Scopus (45) Google Scholar]. The solutions, championed by such countries as India [[26]Caduff C. Booth C.M. Pramesh C.S. Sullivan R. India's new health scheme: what does it mean for cancer care?.Lancet Oncol. 2019; 20: 757-758Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar] and, until recently, Mexico [[27]Agren D. Farewell Seguro Popular.Lancet. 2020; 395: 549-550Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar], require the introduction of strong social insurance systems, coupled to well-governed cancer services and systems, which we address below. In this regard, research on developing new and sustainable financing solutions is critical to ensuring financial protection to individuals suffering from cancer.GovernanceFiscal policy aside, there remains too little insight and capability in understanding the political economy of cancer, in particular the conditions that shape a cancer service's development within wider macroeconomic and political contexts. Such deficits in research and policymaking are mirrored at the most basic level with a failure to integrate properly designed cost-effectiveness analyses into clinical studies of new health technologies [[28]Brown M.L. Lipscomb J. Snyder C. The burden of illness of cancer: economic cost and quality of life.Ann Rev Publ Health. 2001; 22: 91-113Crossref PubMed Scopus (219) Google Scholar,[29]Lievens Y.R.D. Aggarwal A. Financial and economic considerations in radiation oncology.in: Dyk J.V. The modern technology of radiation oncology. Medical Physics Publishing, Madison, WI2020Google Scholar].There is an emerging understanding of political economy and its importance to ensuring equitable and efficient cancer care delivery and sustainable funding, e.g. Health Technology Assessment (HTA), commissioning and reimbursement systems, and pharmaceutical regulation [[30]Chalkidou K. Marten R. Cutler D. Culyer T. Smith R. Teerawattananon Y. et al.Health technology assessment in universal health coverage.Lancet. 2013; 382: e48-e49Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar]. However, the benefits with respect to outcomes, affordability and equality achieved by implementing mulitlayered governance from mandated clinical practice guidelines through to sophisticated HTA mechanisms coupled to pricing and reimbursement models are not being universally replicated across all high income countries (HICs) or LMICs [[31]Chamova J. Stellalliance A. Mapping of HTA national organisations, programmes and processes in EU and Norway. Publications Office of the European Union, 2017Google Scholar,[32]Tantivess S. Chalkidou K. Tritasavit N. Teerawattananon Y. Health Technology Assessment capacity development in low- and middle-income countries: experiences from the international units of HITAP and NICE.F1000Res. 2017; 6: 2119Crossref PubMed Scopus (44) Google Scholar]. Some major economies, notably India [[33]Pramesh C.S. Badwe R.A. Borthakur B.B. Chandra M. Raj E.H. Kannan T. et al.Delivery of affordable and equitable cancer care in India.Lancet Oncol. 2014; 15: e223-e233Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar], have started to address the governance of its complex private–public mosaic health system through the creation of a National Cancer Grid [[34]Pramesh C.S. Badwe R.A. Sinha R.K. The national cancer grid of India.Indian J Med Paediatr Oncol. 2014; 35: 226-227Crossref PubMed Scopus (45) Google Scholar] and embedded processes towards HTA (e.g. Choosing Wisely) [[35]Pramesh C.S. Chaturvedi H. Reddy V.A. Saikia T. Ghoshal S. Pandit M. et al.Choosing wisely India: ten low-value or harmful practices that should be avoided in cancer care.Lancet Oncol. 2019; 20: e218-e223Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. But such examples remain the exception and without a better understanding of how the policy environment influences access and affordability to proven innovations, systems will continue to miss opportunities for delivering greater value in the delivery of services [36Aggarwal A. Sullivan R. Affordability of cancer care in the United Kingdom – is it time to introduce user charges?.J Cancer Policy. 2014; 2: 31-39Crossref Scopus (25) Google Scholar, 37Lievens Y. Audisio R. Banks I. Collette L. Grau C. Oliver K. et al.Towards an evidence-informed value scale for surgical and radiation oncology: a multi-stakeholder perspective.Lancet Oncol. 2019; 20: e112-e123Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 38Sullivan R. Aggarwal A. Health policy: putting a price on cancer.Nat Rev Clin Oncol. 2016; 13: 137-138Crossref PubMed Scopus (10) Google Scholar].The critical solution to governance is political and clinical cancer leadership at all levels of the system to underpin and sustain improvements in cancer survival, particularly the critical role of clinicians for translating policy into action [[39]Morris M. Seguin M. Landon S. McKee M. Nolte E. Exploring the role of leadership in facilitating change to improve cancer survival: an analysis of experiences in seven high income countries in the International Cancer Benchmarking Partnership (ICBP).Int J Health Policy Manag. 2021; Crossref PubMed Google Scholar]. But with such leadership comes a need for building experience and expertise in the tools for delivering good governance; political science, health economics, policy, etc. The assumption that clinical excellence equates to good leadership and governance is as flawed a belief in cancer as it is in health care per se.Human Resources and InfrastructureDeficits in human resources are now a universal feature of global cancer, albeit on different scales when comparing HICs and LMICs. The Organisation for Economic Co-operation and Development (OECD) metrics [[40]https://data.oecd.org/health.htm.Google Scholar] allow us to understand how disparities exist across HICs in the provision of core health and cancer care services from staff (nurses, primary care practitioners, secondary care specialists) to beds and imaging facilities, including staggering equipment shortfalls, even in highly socialised high income systems [[41]Lievens Y. Defourny N. Coffey M. Borras J.M. Dunscombe P. Slotman B. et al.Radiotherapy staffing in the European countries: final results from the ESTRO-HERO survey.Radiother Oncol. 2014; 112: 178-186Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar,[42]Grau C. Defourny N. Malicki J. Dunscombe P. Borras J.M. Coffey M. et al.Radiotherapy equipment and departments in the European countries: final results from the ESTRO-HERO survey.Radiother Oncol. 2014; 112: 155-164Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar]. Deficits in LMICs are even more stark; multiple, self-perpetuating deficits from pathology to surgery compound systems' weaknesses [[3]Fleming K.A. Horton S. Wilson M.L. Atun R. DeStigter K. Flanigan J. et al.The Lancet Commission on diagnostics: transforming access to diagnostics.Lancet. 2021; 398: 1997-2050Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar]. Without addressing these basic shortfalls in workforce and equipment needed to deliver evidence-based care – manifest as lengthening of waiting lists or reduced access – health outcomes will continue to stagnate or worsen.Evidence is crucial to effect change. Modelling research, for example in understanding the deficit in surgical workforce for cancer care, has been instrumental in informing policy [[43]Perera S.K. Jacob S. Wilson B.E. Ferlay J. Bray F. Sullivan R. et al.Global demand for cancer surgery and an estimate of the optimal surgical and anaesthesia workforce between 2018 and 2040: a population-based modelling study.Lancet Oncol. 2021; 22: 182-189Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. Likewise, health systems research on cancer pathways around the world examining deficits in human resources leading to diagnostic and treatment delays has been a major foundation for post-pandemic systems planning [[44]Hanna T.P. King W.D. Thibodeau S. Jalink M. Paulin G.A. Harvey-Jones E. et al.Mortality due to cancer treatment delay: systematic review and meta-analysis.BMJ. 2020; 371: m4087Crossref PubMed Scopus (289) Google Scholar]. Policies to support research capacity building (given the deficits in LMIC-led research compared with those from HICs) are necessary, to avoid the ‘one size fits all’ approach to cancer control based on HIC systems and infrastructure [[45]Ranganathan P. Chinnaswamy G. Sengar M. Gadgil D. Thiagarajan S. Bhargava B. et al.The International Collaboration for Research methods Development in Oncology (CReDO) workshops: shaping the future of global oncology research.Lancet Oncol. 2021; 22: e369-e376Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar].Quality Assurance and Health Service DeliveryHealth systems research seeks to achieve two major aims. First, to provide evidence to reduce the ‘gap’ between the worst and best outcomes. Second, to raise the overall quality bar. The foundations of delivering high-quality care in any cancer system irrespective of development level is the measurement and evaluation of three major components of the health service [[46]Donabedian A. Evaluating the quality of medical care. 1966.Milbank Q. 2005; 83: 691-729Crossref PubMed Scopus (1314) Google Scholar]: (i) the structure of services (i.e. hospital attributes including staffing ratios and equipment availability); (ii) the process of care delivery (e.g. procedures volume, waiting times, preoperative care); (iii) the outcomes actually delivered by providers, i.e. the effect on the patient (e.g. reduced mortality).However, the reality is that at present most health systems across all income settings, despite the billions invested in biomedical research and new technologies, do not have the integrated data architectures or reporting platforms to be able to understand the quality of care delivered at a hospital or population level [[47]Palta J.R. Efstathiou J.A. Bekelman J.E. Mutic S. Bogardus C.R. McNutt T.R. et al.Developing a national radiation oncology registry: from acorns to oaks.Pract Radiat Oncol. 2012; 2: 10-17Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar]. Without this level of transparency there is no way of understanding the ‘gaps’ between high- and low-level performance, or the necessary incentives to create the quality improvement culture that can support improvements in quality at low cost and to scale, as well as support timely reimbursement and adoption of effective innovations [[48]Berwick D.M. James B. Coye M.J. Connections between quality measurement and improvement.Med Care. 2003; 41 (I-30-I-8)Crossref PubMed Scopus (390) Google Scholar].In this respect the solutions are clear. Improving quality and efficiency in cancer systems requires public reporting programmes and audit, encompassing all three major treatment domains of surgery, radiotherapy and systemic therapies [[49]Aggarwal A. Nossiter J. Parry M. Sujenthiran A. Zietman A. Clarke N. et al.Public reporting of outcomes in radiation oncology: the National Prostate Cancer Audit.Lancet Oncol. 2021; 22: 207-215Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar,[50]Burns E.M. Pettengell C. Athanasiou T. Darzi A. Understanding the strengths and weaknesses of public reporting of surgeon-specific outcome data.Health Aff. 2016; 35: 415-421Crossref PubMed Scopus (28) Google Scholar]. Central governance is required to fund and mandate data collection on incidence, outcomes and key quality metrics in the public and private sectors with the level and granularity being proportional to the complexity and level of systems development. Without this foundation, health systems strengthening, particularly in LMIC, through a quality agenda is liable to fail.From a health services perspective, we still do not know how we should best organise care. Patients are increasingly moving across borders to seek care and multiple providers mean that most countries have complex and parallel pathways of care in private and public sectors [[51]Yusuf M.A. Hussain S.F. Sultan F. Badar F. Sullivan R. Cancer care in times of conflict: cross border care in Pakistan of patients from Afghanistan.Ecancermedicalscience. 2020; 14: 1018Crossref PubMed Google Scholar]. Although some countries have a plurality of providers to support patient choice and hospital competition to drive quality improvement, other public sector systems are moving towards greater consolidation of cancer services to fewer high-volume centres, e.g. UK, China [52Gruen R.L. Pitt V. Green S. Parkhill A. Campbell D. Jolley D. The effect of provider case volume on cancer mortality: systematic review and meta-analysis.CA Cancer J Clin. 2009; 59: 192-211Crossref PubMed Scopus (174) Google Scholar, 53Aggarwal A. Lewis D. Mason M. Purushotham A. Sullivan R. van der Meulen J. Effect of patient choice and hospital competition on service configuration and technology adoption within cancer surgery: a national, population-based study.Lancet Oncol. 2017; 18: 1445-1453Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 54Baicker K. Levy H. Coordination versus competition in health care reform.New Engl J Med. 2013; 369: 789-791Crossref PubMed Scopus (49) Google Scholar]. Evidence for a volume–outcome relationship exists for some cancer surgical procedures, but there is little evidence in radiation and systemic therapies and there is very limited research to support how and where services should be centralised within a health system to improve quality and prevent the inequities in access that have been observed [[55]Parry M.G. Sujenthiran A. Cowling T.E. Nossiter J. Cathcart P. Clarke N.W. et al.Impact of cancer service centralisation on the radical treatment of men with high-risk and locally advanced prostate cancer: a national cross-sectional analysis in England.Int J Cancer. 2019; 145: 40-48Crossref PubMed Scopus (13) Google Scholar,[56]Vallance A.E. vanderMeulen J. Kuryba A. Botterill I.D. Hill J. Jayne D.G. et al.Impact of hepatobiliary service centralization on treatment and outcomes in patients with colorectal cancer and liver metastases.Br J Surg. 2017; 104: 918-925Crossref PubMed Scopus (31) Google Scholar]. Clearly understanding this trade-off in a context-specific manner will ensure that the organisation of services will protect the most vulnerable and act to reduce access disparities [[57]Aggarwal A. van der Geest S.A. Lewis D. van der Meulen J. Varkevisser M. Simulating the impact of centralization of prostate cancer surgery services on travel burden and equity in the English National Health Service: a national population based model for health service re-design.Cancer Med. 2020; 9: 4175-4184Crossref PubMed Scopus (6) Google Scholar].Research and ImplementationNo innovation improves patient care and outcomes without first navigating its way through the health system. Healthcare systems determine the breadth and extent of innovation by creating the environment for translational and clinical research. Implementation and scale up, both intrinsic aspects of health systems strengthening, further determine whether any innovation is affordable and pro-equity. Yet in a system where you pay to play, global cancer research largely focuses on basic science and systemic therapies and is increasingly funded by industry [[58]Mukherji D. Murillo R.H. Van Hemelrijck M. Vanderpuye V. Shamieh O. Torode J. et al.Global cancer research in the post-pandemic world.Lancet Oncol. 2021; 22: 1652-1654Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar,[59]Wells J.C. Sharma S. Del Paggio J.C. Hopman W.M. Gyawali B. Mukherji D. et al.An analysis of contemporary oncology randomized clinical trials from low/middle-income vs high-income countries.JAMA Oncol. 2021; 7: 379-385Crossref PubMed Scopus (36) Google Scholar]. A recent analysis reviewing publication outputs in lung cancer found that 60% of research focused on systemic therapies and basic science research compared with 8% of outputs on radiation research, 4% on early diagnosis and 2% on screening research [[60]Aggarwal A. Lewison G. Idir S. Peters M. Aldige C. Boerckel W. et al.The state of lung cancer research: a global analysis.J Thorac Oncol. 2016; 11: 1040-1050Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar]. What gains could potentially be made for the population from a greater research emphasis on early diagnosis and more effective curative locoregional treatments? Additionally, improving our understanding of how to minimise disparities in access to care through health services research could make a huge difference to population-level survival, yet only 2% of radiation research is devoted to this area [[61]Aggarwal A. Lewison G. Rodin D. Zietman A. Sullivan R. Lievens Y. Radiation therapy research: a global analysis 2001–2015.Int J Radiat Oncol Biol Phys. 2018; 101: 767-778Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar]. This speaks to the urgent need for the worlds' cancer research funders, particularly federal and philanthropic, to re-assess the balance of their research portfolio investments and their overall strategic direction.Healthcare systems are faced with the continual challenge of ensuring that the high-quality basic science and applied research influences practice [[62]Ioannidis J.P.A. Why most clinical research is not useful.PLOS Med. 2016; 13e1002049Crossref PubMed Scopus (316) Google Scholar]. It can take 17–20 years to get clinical innovations into practice and fewer than 50% of clinical innovations ever make it into general usage [[63]Mosteller F. Innovation and evaluation.Science. 1981; 211: 881-886Crossref PubMed Scopus (69) Google Scholar]. The answer for improving this damning statistic is through a greater investment in implementation science – the second translational gap – which seeks to test strategies to enhance the usage of clinical innovation, by considering the health system dynamics and multiple actors (patients, clinicians, providers, policy environment, industry) that could impede or facilitate evidence adoption [[64]