The oncology world is buzzing about daraxonrasib. A pan-RAS inhibitor associated with a 60% reduction in mortality in pancreatic cancer does not come along often. Median overall survival doubled: 13.2 months versus 6.6 months with standard chemotherapy. These are the results that make headlines, fill American Society of Clinical Oncology auditoriums, and remind us why we went into medicine.

They also reflect a real achievement. As a profession, we have become much better at identifying promising drugs and moving them toward patients quickly. But speed has created a problem that receives far less attention than the breakthrough itself.

Accelerated approval allows drugs to reach the market on the basis of surrogate endpoints, such as tumor shrinkage, biomarker changes, or delayed progression. These findings can be meaningful. But they are not the same as proving that patients live longer, feel better, or function better.

That distinction is supposed to be resolved after approval, through confirmatory trials. Yet by then, the financial architecture is often already in place. Insurers establish prior authorization criteria. Copays and coinsurance are assigned. A treatment enters guidelines, clinical pathways, and conversations between oncologists and patients.

By the time confirmatory data arrive, the drug may already be woven into practice, its price normalized, and its access rules effectively predetermined.

The history of bevacizumab in metastatic breast cancer is a good illustration of this phenomenon. Bevacizumab received accelerated approval in 2008 based on progression-free survival. However, subsequent trials did not show an overall survival benefit and raised safety concerns. As a result, the FDA formally withdrew the breast cancer indication from bevacizumab’s label in 2011. For years, however, patients and payers had been asked to absorb the cost and toxicity of a treatment whose benefit remained uncertain.

I am not arguing against accelerated approval. Patients with life-threatening illness and few alternatives should not have to wait unnecessarily for promising therapies. But early approval should not become a shortcut around the harder questions: Does this treatment improve outcomes that matter to patients? How quickly will that answer be known? And what happens when its price is set before either question is settled?

Sometimes, as a field, we accelerate the drug approval but not the system required to make the drug attainable. But approval is not the same as access. An FDA-approved therapy that is supported by National Comprehensive Cancer Network guidelines can still remain out of reach for a patient because of insurance design, geography, out-of-pocket costs, or the practical burden of navigating a complex health system.

Precision oncology and social determinants of health research make the divide between approval and access even starker. Enrollment in biomarker-driven cancer trials often skews away from the patients who comprise the majority of the U.S. cancer population, and access to the genetic counseling and molecular testing that make precision medicine possible varies markedly by socioeconomic status. A drug’s efficacy in a trial population does not guarantee that it will reach or even work as well for the population that actually needs it.

Revolution Medicines is currently providing daraxonrasib for free through an expanded access program. That is a meaningful bridge for patients who can access it. But expanded access is not a long-term pricing policy. Daraxonrasib recently obtained FDA approval and the annual price is about $477,000 a year. While we won’t know what the final cost will be to the patient with insurance, this may be a cost-prohibitive medicine for many people.

The gap between approval and access does not just occur in cancer care. It is seen in routine medicine. Not long ago, I prescribed ciprofloxacin-dexamethasone ear drops for a patient with otitis externa. A 7.5 mL bottle cost him $80 out of pocket with insurance. A GoodRx coupon brought it down to $60, but the listed price was closer to $250. Treatments don’t have to be novel or exotic to be expensive — both routine and breakthrough care can fail patients in the same way.

Not long after this patient encounter, I went in for my own appointment, which I scheduled as a routine annual physical. I had no complaints. When my primary care physician asked if anything had been bothering me, I hesitated, then mentioned some mild fatigue. We talked through a basic differential. Maybe hypothyroidism, maybe iron deficiency. She ordered a standard set of labs. A few weeks later, I was billed $307.80 for the visit and $279 for the labs. When I called my insurance company, I was told the issue was simple. By mentioning a symptom, my “annual physical” had been reclassified as a diagnostic visit. Preventive care, I learned, is only free if you are perfectly well, or at least if you say you are.

These routine healthcare experiences are not equivalent to a patient trying to obtain a six-figure, lifesaving cancer drug. But they arise from the same underlying system in which the cost of care is frequently discovered after the clinical decision has already been made. And they all raise the same uncomfortable question: If this is what it costs to be a relatively healthy patient in America, what does it cost to be a sick one?

One project I’ve been interested in has been studying treatment costs for patients with relapsed or refractory Hodgkin lymphoma, many of whom have failed first-line therapy and often second- and third-line regimens. Their care is a tour through modern oncology with checkpoint inhibitors, antibody-drug conjugates, and stem cell transplants.

Among the first 100 patients I analyzed, the median cost of treatment — based on wholesale acquisition cost for drugs along with transplant costs — was $456,303, with a median of two lines of therapy. One drug I looked at was brentuximab, and I found that in many cases, post-transplant maintenance therapy with brentuximab costs more than the transplant itself. And the prices keep rising. The wholesale acquisition cost of brentuximab has doubled over the past decade, from $19,725 per cycle in 2016 to $39,510 in 2025. Six palliative cycles today cost more than a full 16-cycle maintenance course nine years ago.

When the costs of cancer treatment reach this scale, access becomes a clinical variable. It affects whether patients start treatment on time, whether they can travel for it, whether they can afford the supportive medications that make it tolerable, and whether they can remain financially stable long enough to receive the next line of therapy.

Accelerated pathways have a vital place in oncology, but I believe faster approval should come with an equally serious commitment to confirmatory evidence, affordability, and equitable delivery. When drugs like daraxonrasib make headlines, we should not only be asking how well they work, but also who will realistically be able to take them.

As clinicians, we like to believe that prescribing is a purely medical decision. Increasingly, it’s not. Every treatment recommendation carries an unspoken second question — can this patient actually afford what I’m about to offer?

If clinicians don’t ask that question, we risk practicing a version of medicine where cures exist but only in theory.