The pace of investment in cancer treatment has not followed the needs. Coverage is still poor and in some cases worsening, in parts of the world. By 2040 there will be 26 million new cases of cancer every year. About half of these cases will need radiotherapy, similarly half will need chemotherapy and about 55% will require surgery. Nearly 70% of cases will occur in low and middle income countries (LMIC) where increasing wealth will lengthen life expectancy and the ability to provide cancer treatments. Investment in cancer treatment will save lives and increase productivity. We estimate that it will cost $184 billion to scale up radiotherapy access in LMIC so that all patients can get access by 2035. This will save nearly 1 million lives per year and create a nett benefit of $365 billion. For chemotherapy the demand for cancer clinicians will increase from 65,000 worldwide to 100,000 by 2040. There are many barriers to the sustainable development of cancer services. Cancer control does not happen in isolation and requires functional government, health services, pathology and diagnostics. Small island states are poorly suited to the traditional models of service delivery because their small and dispersed populations.