Raffaella Casolino

Clinical trials are essential to advancing cancer control, yet access and participation remain unequal globally. The World Health Organization (WHO) established the International Clinical Trials Registry Platform (ICTRP) to enable a complete view of interventional clinical research for all those involved in healthcare decision-making and to identify actionable goals to equitable participation at the global level. A review of 89,069 global cancer clinical trials registered in the WHO ICTRP between 1999 and December 2022 revealed a cancer clinical trial landscape dominated by high-income countries and focused on pharmacological interventions, with multinational collaboration limited to only 3% of recruiting trials. Several of the deadliest cancers, including liver, stomach, pancreas and cervical cancer, were consistently missing from the top most-studied cancer types, particularly in Africa and Southeast Asia. In this Review, we summarize the key findings of the WHO global landscape review and discuss strategies to act on these data, which provide critical empirical evidence to inform policy, practice and investment decisions.

The last decade has seen rapid progress in the use of genomic tests, including gene panels, whole‐exome sequencing, and whole‐genome sequencing, in research and clinical cancer care. These advances have created expansive opportunities to characterize the molecular attributes of cancer, revealing a subset of cancer‐associated aberrations called driver mutations . The identification of these driver mutations can unearth vulnerabilities of cancer cells to targeted therapeutics, which has led to the development and approval of novel diagnostics and personalized interventions in various malignancies. The applications of this modern approach, often referred to as precision oncology or precision cancer medicine , are already becoming a staple in cancer care and will expand exponentially over the coming years. Although genomic tests can lead to better outcomes by informing cancer risk, prognosis, and therapeutic selection, they remain underutilized in routine cancer care. A contributing factor is a lack of understanding of their clinical utility and the difficulty of results interpretation by the broad oncology community. Practical guidelines on how to interpret and integrate genomic information in the clinical setting, addressed to clinicians without expertise in cancer genomics, are currently limited. Building upon the genomic foundations of cancer and the concept of precision oncology, the authors have developed practical guidance to aid the interpretation of genomic test results that help inform clinical decision making for patients with cancer. They also discuss the challenges that prevent the wider implementation of precision oncology.

To achieve an oncology workforce that is fit for purpose and sufficient in number, more holistic workforce planning is needed, focusing on educational sector and labor market dynamics. Oncology professionals must be trained and enabled to influence factors affecting their clinical practice including by developing competencies to redesign clinical practice, reduce burnout, and improve productivity and care.

Pancreatic ductal adenocarcinoma (PDAC) is usually diagnosed at an advanced, incurable, stage and has an extremely poor prognosis. Systemic chemotherapy represents the standard treatment either in the pre-operative, adjuvant and palliative setting, which is associated with only modest improvement in survival. More recently, advances in cancer genomic sequencing have unravelled the molecular heterogeneity of PDAC and identified small patient subgroups harbouring unique actionable aberrations in BRCA, NTRK, NRG1 and mismatch repair genes paving the way to a more personalised approach for this tumour. However, the evolution of PDAC treatment towards a successful precision approach presents many challenges. In this review, we discuss the current standard treatments of PDAC, from early stage to advanced disease, and we illustrate the opportunities and challenges of precision medicine for this deadly cancer.