Global cancer research in the post-pandemic world.

The COVID-19 pandemic has dramatically altered the global landscape for cancer prevention, diagnosis, and treatment. Whether or not this change will ultimately be a force for good for driving progress towards universal health coverage for cancer control is unknown. What is certain is that delivering better, more affordable, and equitable cancer outcomes will require all countries to energise (or re-energise) and in some cases reprioritise their research ecosystems. The pre-existing barriers to achieve strong national research frameworks in many countries are high. Some of the major barriers are low national science and technology intensity (outputs) and poor public sector funding coupled with reductions in the clinical academic workforce.

Nevertheless, the global cancer community has responded remarkably well to the research challenges resultant from the COVID-19 pandemic. The pandemic has led to crucial discussions with the oncology community about the value of cancer care interventions. In some contexts, clinicians have had to prioritise which investigations and treatments can offer the greatest benefit to patients, while simultaneously recognising and deimplementing those that offer very small benefits or might be harmful (over treatment or unfavourable risk-benefit ratio). Looking forward, it will be essential that this element of introspection with regards to the value of cancer care remains at the forefront of clinical research activities. The global cancer community has also reoriented itself to understand the vulnerabilities and risks of SARS-CoV-2 to different populations of patients with cancer, evaluate the effectiveness of COVID-19 vaccines in immunocompromised patients, and develop high-level health system and policy tools to better understand and mitigate the impact of delays in cancer diagnosis and treatment. This research effort has been inconsistent, mostly taking place in high-income settings and some middle-income settings—eg, China and India. Furthermore, the work has largely been undertaken without substantial financial support from major cancer research funders. There remains a major divide between the aspirations of learning from the pandemic, building back better health systems for global cancer care, and the realities of what and how much global funding has been made available to achieve this. Crucial research is being left behind and essential questions remain totally or partially unsolved. These include defining how different national cancer care systems were affected. How did these systems adapt? What has been the effect of any mitigation measures applied? How should the global cancer community address differences in COVID-19 vaccine effectiveness? These are major unknowns, and a failure to understand and to answer these questions might have a devastating effect on the resilience of cancer care systems in the future when faced with the next pandemic. If we are to address these challenges, then there needs to be a collective global cancer research effort to prevent widening of existing disparities in cancer outcomes.

WHO has recently suggested that, although most countries now have national cancer control plans, progress is uneven towards the goals set out in the World Cancer Declaration. What is not made apparent is that the majority of national cancer control plans have little to say about cancer research. Yet all evidence shows that, to achieve affordable, equitable, and high-quality outcomes, countries must be research active. The pandemic has, more than any other recent event, illustrated gross global inequalities both in where research is undertaken and in who benefits from such efforts. Just nine countries in the world control nearly 70% of the world's cancer research. The one remarkable statistic about this is China's meteoric rise to second place, just behind the USA in terms of gross cancer research output. Although research might have been stalled in high-income settings, our work suggests that the pandemic is highly unlikely to affect future trajectories in these settings, with the most detrimental effects likely to be on those countries most in need of strengthening their cancer research ecosystems, which is low-income and middle-income countries (LMICs). Again, a combination of factors, from macro-economic downturns to loss of health-care professionals, will be most acutely felt across LMICs and, in turn, negatively affect nascent cancer research collaborations.

The directors of the USA National Cancer Institute (NCI) and the NCI Centre for Global Health jointly called for cancer as a global health priority. This timely and important call recognises the reality of where we stand today. A deeply asymmetric global cancer research ecosystem, dominated by the basic science and biopharmaceutical agendas, set by high-income countries and the private sector, with little recognition or regard to health systems strengthening. High-income country commitments to global cancer research remains small, with less than 4% of total annual outputs (publications) coauthored with individuals in LMICs (table ; data available from Institute of Cancer Policy, King's College London, London, UK ). Yet the pandemic has shown that countries and health systems can learn a great deal from each other. This bidirectional flow challenges the classic neocolonial unidirectional flow of knowledge whereby contributions and research from lower-resource settings are often not given adequate recognition. It is our collective view that we need to set in motion an international agenda around research on cancer control systems and policies in a post-pandemic world, while enabling knowledge sharing and transfer across institutions and countries that are supported by direct research assistance—ie, high-income countries supporting global research as well as by improvements to domestic research and development expenditure on cancer research.

Table

Total global cancer research publication outputs in the 10 years before the COVID-19 pandemic (February, 2010, to February, 2020) from the top nine output countries, as a percentage of world total cancer research publications and percentage of publications with coauthors from LMICs

	Number of publication outputs (% of world total)*	Number of publication outputs with authors from LMICs (% of country total)
UK	63 759 (5·75%)	2452 (3·85%)
France	48 895 (4·41%)	1868 (3·82%)
Australia	32 789 (2·95%)	1228 (3·75%)
Canada	43 936 (3·96%)	1462 (3·33%)
Germany	69 990 (6·31%)	1915 (2·74%)
USA	317 950 (28·65%)	7806 (2·46%)
Spain	32 622 (2·94%)	766 (2·35%)
Italy	66 464 (5·99%)	1289 (1·94%)
China	254 171 (22·90%)	1884 (0·74%)
Top nine country total	773 975 (69·74%)	14 805 (1·91%)
World total	1 109 800	68 893 (6·21%)

Data are n (%) or n. LMICs=low-income and middle-income countries.

The outputs of the nine individual countries sum to 83·86%, but the combined total is only 69·74% because of double counting of collaborative papers.

DM reports institutional research grants from Astellas and Bristol Myers Squibb; and honoraria for educational events from Astellas, Bayer, Janssen, Merck Sharpe and Dohme, Bristol Myers Squibb, and AstraZeneca. All other authors declare no competing interests. The COVID-19 and Cancer Task Force receives funding from the UK Research and Innovation as part of the Global Challenges Research Fund; Research for Health in Conflict in the Middle East and North Africa (R4HC-MENA) project (grant number ES/P010962/1). The funding agency has no role in the writing of the manuscript or decision to submit it for publication.