Drug shortages have become a persistent feature of oncology practice. Although shortages periodically capture national attention when widely used agents such as cisplatin or carboplatin become scarce, the problem extends well beyond any single drug.1 Current and recent shortages have affected multiple antineoplastic and supportive-care agents, including older generic drugs that remain foundational components of curative and life-prolonging regimens.2 For patients and clinicians, the consequences can be profound. A treatment plan that was developed based on tumor biology, clinical evidence, patient preference, and years of accumulated experience may suddenly need to be reconsidered.
Fortunately, oncology practices are not powerless in the face of shortages. Professional organizations, including the American Society of Clinical Oncology (ASCO), have developed practical and ethical frameworks for managing limited supplies. When shortages occur, institutions should rapidly establish multidisciplinary oversight that involves oncologists, pharmacists, nursing leadership, administrators, and ethics expertise, when appropriate. Available inventory should be assessed across the health system rather than within individual clinics, and allocation policies should be transparent, consistent, and based on clinical benefit rather than a patient’s ability to navigate the health system.3
Several strategies can help preserve limited supplies. When therapeutically comparable alternatives exist, clinicians may substitute another agent or regimen. Dose rounding, vial-size optimization, reduction of avoidable waste, and careful pharmacy inventory management can extend available supply. In selected circumstances, treatment intervals or doses may be adjusted within evidence-supported ranges. Conversely, scarce agents should generally be prioritized for situations in which they provide a demonstrated survival or curative benefit, particularly when suitable alternatives are lacking. Importantly, these decisions should be individualized; substitution is not synonymous with equivalence, and differences in efficacy, toxicity, comorbidities, and treatment goals must remain central to clinical decision-making.4
The recurrent nature of oncology drug shortages reflects vulnerabilities throughout the pharmaceutical supply chain. Many indispensable chemotherapy drugs are inexpensive sterile generics produced by relatively few manufacturers. Economic pressure, manufacturing disruptions, quality problems, limited redundancy, and dependence on concentrated sources of active pharmaceutical ingredients can transform the loss of a single manufacturing facility or supplier into a national clinical problem. In 2026, ASCO continues to call for policies that strengthen manufacturing reliability, improve transparency regarding the origins of drugs and their ingredients, diversify supply chains, and create incentives that reward manufacturers for maintaining dependable production rather than simply producing at the lowest possible cost.5
Several additional approaches deserve consideration. Greater visibility into the pharmaceutical supply chain could enable the FDA and health systems to identify vulnerabilities before they lead to shortages. Strategic reserves of selected essential medicines or active pharmaceutical ingredients could provide a buffer during temporary disruptions. Long-term purchasing agreements and other economic incentives could help stabilize markets for low-margin generic drugs. Investment in advanced and flexible manufacturing could enable production to shift more rapidly when a single supplier fails. Expanding domestic manufacturing capacity may also improve resilience, although this should complement rather than replace a diversified international supply chain.6
Equity must also remain central to these efforts. Large health systems may have greater purchasing power, pharmacy infrastructure, and ability to redistribute inventory than small practices or rural cancer centers. A national solution cannot simply shift scarce drugs toward institutions best positioned to obtain them. Reliable access to essential cancer medicines should not depend on where a patient lives or receives treatment.
There is an uncomfortable irony in having unprecedented scientific capability to treat patients with cancer while occasionally lacking reliable access to medicines developed decades ago. Innovation in oncology must therefore mean more than discovering the next therapy. It must also include building a system capable of reliably delivering every effective therapy, from the newest targeted agent to the oldest generic chemotherapy, to every patient who needs it.
As oncologists, we can and should steward scarce resources responsibly during shortages. But our patients deserve more than increasingly sophisticated strategies for managing scarcity. The longer-term goal must be to make those strategies unnecessary.
References
1. Westin J, Sherwood S, Hagerty K, Gralow J. Crisis of cancer drug shortages: understanding the causes and proposing sustainable solutions. JCO Oncol Pract. 2026:22(1):13-15. doi:10.1200/OP-25-00381
2. Socal MP, Acha J, Yang CY, et al. Key drivers and mitigation strategies of oncology drug shortages 2023 to 2025. Cancer J. 2025;31(5):e0791. doi:10.1097/PPO.0000000000000791
3. Hantel A, Spence R, Camacho P, et al. ASCO ethical guidance for the practical management of oncology drug shortages. J Clin Oncol. 2024;42(3):358-365. doi:10.1200/JCO.23.01941
4. Santos ES, Oliver TK, Lacchetti C, et al. Drug shortages in oncology: ASCO clinical guidance for alternative treatments. JCO Oncol Pract. 2024;20(1):19-32. doi:10.1200/OP.23.00545
5. Policies that strengthen supply chains needed to mitigate drug shortages. ASCO. April 7, 2026. Accessed August 28, 2026. https://www.asco.org/news-initiatives/policy-news-analysis/strong-supply-change-policies-needed-to-mitigate-drug-shortages
6. National Academies of Sciences, Engineering, and Medicine. Improving the Resilience of the U.S. Pharmaceutical Supply Chain Through Make–Buy–Invest Strategic Actions: Proceedings of a Workshop—in Brief. National Academies Press; 2025. doi:10.17226/29382
