This Lancet Oncology Commission maps the global state of cancer genomics and reaches two conclusions that sit uneasily together. Access is profoundly unequal, within countries as well as between them, leaving large numbers of patients without interventions their own guidelines indicate. And the benefit being rationed is more limited than the field's momentum implies.
The Commission is direct about where gains are real: a small number of well validated biomarker-treatment pairings, generally backed by a companion diagnostic. Comprehensive genomic profiling and tumour-agnostic strategies may open options for selected patients, but only a few of those receiving matched therapy derive meaningful benefit. It names a paradox of success - expansion has raised cognitive, organisational, data, workforce and financial burdens faster than population-level evidence of benefit has accumulated. Genomic research itself is concentrated in high-income settings and populations of predominantly European ancestry, which limits what the variants mean elsewhere.
For Indian oncology the practical content is the resource-stratified implementation framework: which tests are worth doing at which level of system capability, rather than treating a large panel as the aspiration. A targeted test with a companion diagnostic and an available drug behind it beats a broad panel whose actionable findings cannot be acted on. Variant interpretation in South Asian ancestry is also weaker, which raises the rate of variants of uncertain significance.
- Prefer a validated biomarker-treatment pairing with an available drug over a broad panel.
- Ask what will change if the panel is positive, before ordering it.
- Expect more variants of uncertain significance in under-represented ancestries, including South Asian.
- Comprehensive profiling benefits only a minority of those receiving matched therapy.
- Use the resource-stratified framework to decide what your service should offer, not what is technically possible.
Why it matters
The field's expansion has outrun its evidence, and the cost of that falls hardest on systems that can least afford an unactionable result.
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