China-to-Global Oncology Licensing (2021–2026): A Narrative Review for Medical Professionals

Introduction: A Structural Inflection in Global Drug Development

Between January 2021 and June 2026, China-origin oncology assets have attracted a sustained wave of licensing agreements with leading global pharmaceutical companies, signaling a structural reordering of where oncology innovation is discovered and how multinational organizations source their pipelines. The cumulative financial scale of these transactions — with 2025 alone reportedly totaling $135.7 billion in total deal value across all therapeutic areas — is striking, but the more meaningful signal is qualitative: China has transitioned from a cost-competitive fast-follower market to a recognized source of clinically differentiated, novel-mechanism oncology therapeutics 1. For medical professionals, understanding these transactions is not merely an exercise in corporate finance; the assets being licensed today will define clinical options for patients in the United States, Europe, and beyond within the next several years.

The Scale of Transformation

The repricing of Chinese biotech assets underscores market recognition of their quality. Average upfront payments for China-sourced oncology licensing deals rose from $52 million in 2022 to $172 million by early 2026 — a 230% increase reflecting parity with innovation originating from established hubs in Boston, San Diego, or Cambridge 1. Chinese companies now account for approximately 23% of global drug candidates in development, second only to the United States, and China's clinical trial volume has surpassed that of the US 1. More than half of the global antibody-drug conjugate (ADC), bispecific antibody (BsAb), and CAR-T (chimeric antigen receptor T-cell) clinical pipeline is now China-originated or China-partnered 2. These are not peripheral statistics; they define the landscape in which oncologists will encounter novel treatment options in phase III trials and, increasingly, in approved indications.

Dominant Modality: Antibody-Drug Conjugates

ADCs — constructs pairing a tumor-targeting antibody with a cytotoxic payload via a chemical linker — have emerged as the defining modality of this licensing wave. China's strength in linker chemistry, payload innovation, and conjugation technology has produced a series of assets that have attracted some of the largest transactions in oncology history.

The Kelun-Biotech and Merck (MSD) deal, announced in December 2022, exemplifies this. Merck licensed seven preclinical ADC candidates for $175 million upfront and up to $9.3 billion in milestone payments, reflecting confidence in Kelun-Biotech's proprietary platform spanning target discovery, payload screening, linker design, and GMP manufacturing 4. Subsequent development yielded sacituzumab tirumotecan (sac-TMT; MK-2870), a TROP2-targeting ADC with a novel irreversible but hydrolyzable linker and a drug-to-antibody ratio of 7.4, now in 15 global phase III trials across six tumor types 16. Critically, the phase III OptiTROP-Lung04 trial, data for which were presented at ESMO 2025, demonstrated that sac-TMT significantly prolonged median progression-free survival (PFS) to 8.3 months versus 4.3 months with chemotherapy (hazard ratio [HR] 0.49), alongside a 40% reduction in interim risk of death, in EGFR-mutated non-small cell lung cancer (NSCLC) following EGFR tyrosine kinase inhibitor (TKI) failure — a setting historically dominated by platinum-based chemotherapy 3839. The US Food and Drug Administration (FDA) granted Breakthrough Therapy Designation (BTD) for sac-TMT in December 2024 for this defined EGFR-mutated NSCLC post-TKI setting 35.

Hansoh Pharma's dual partnership with GSK in late 2023 illustrates further ADC diversification. HS-20093, a B7-H3-targeted ADC with a topoisomerase inhibitor payload, commanded $185 million upfront and up to $1.525 billion in milestones after phase I data demonstrated responses in small cell lung cancer (SCLC), NSCLC, and sarcoma in the ARTEMIS-001 trial 6. DualityBio's collaboration with BioNTech, signed in April 2023 for $170 million upfront and over $1.5 billion in milestones, centered on DB-1303 (trastuzumab pamirtecan), a HER2-targeted third-generation ADC built on DualityBio's DITAC (Duality Immune Toxin Antibody Conjugates) platform 814. By September 2025, a pivotal phase III trial of DB-1303 in China met its primary PFS endpoint in HER2-positive metastatic breast cancer versus trastuzumab emtansine (T-DM1), validating Chinese ADC platforms through controlled registrational evidence 15.

SystImmune's collaboration with Bristol Myers Squibb (BMS), announced in December 2023, stands out for both scale and novelty: BL-B01D1 (izalontamab brengitecan; iza-bren) is a first-in-class bispecific ADC co-targeting EGFR and HER3 with a topoisomerase-I inhibitor payload, aiming to overcome resistance driven by tumor heterogeneity. BMS paid $800 million upfront with total potential deal value of $8.4 billion, and the companies share US development expenses and profits 20. Multiple phase III successes followed: the BL-B01D1-303 trial reported an independent-reviewer-assessed objective response rate (ORR) of 54.6% versus 27.0% for chemotherapy in recurrent/metastatic nasopharyngeal carcinoma 29, and the BL-B01D1-307 trial met dual primary endpoints of PFS and overall survival (OS) in triple-negative breast cancer (TNBC), making iza-bren the first bispecific ADC to report PFS/OS dual positivity in TNBC 28, based on publicly disclosed data.

Bispecific Antibodies and Multi-Target Immuno-Oncology

Bispecific antibodies — engineered proteins that simultaneously bind two distinct antigens — represent the second major pillar of this licensing wave, particularly those coupling PD-1 blockade with anti-angiogenic VEGF inhibition.

Akeso's ivonescimab (AK112/SMT112), a PD-1/VEGF BsAb, was out-licensed to Summit Therapeutics in December 2022 for $500 million upfront and up to $5 billion total 9. The clinical rationale is compelling: dual PD-1 and VEGF blockade addresses angiogenesis-driven immune exclusion, potentially overcoming resistance to single-agent checkpoint inhibition. In the HARMONi-2 phase III trial in China, ivonescimab demonstrated superior PFS compared with pembrolizumab as first-line monotherapy in PD-L1-positive advanced NSCLC, leading to NMPA (China's National Medical Products Administration) approval in April 2025 274445. Critically, the HARMONi global phase III trial subsequently reported a 48% reduction in the risk of disease progression or death versus chemotherapy in EGFR TKI-failed NSCLC — a result broadly consistent with the China-only HARMONi-A trial — establishing that ivonescimab's efficacy is reproducible in Western patient populations 27.

This template was replicated in January 2026 when AbbVie licensed RemeGen's RC148, another PD-1/VEGF bispecific, for $650 million upfront with up to $4.95 billion in milestones and double-digit tiered royalties on net sales in ex-Greater China territories 23. Pfizer's deal for 3SBio's SSGJ-707, a functionally similar PD-1/VEGF bispecific, commanded $1.25 billion upfront plus a $100 million equity investment for a total potential value of approximately $6 billion, one of the largest single-asset China-origin deals disclosed through mid-2026 1213.

Cell Therapies, Radiopharmaceuticals, and Emerging Modalities

Beyond ADCs and BsAbs, the licensing landscape reflects diversification. Legend Biotech's November 2023 agreement with Novartis granted worldwide rights to LB2102, a DLL3-targeted autologous CAR-T candidate for extensive-stage SCLC and large cell neuroendocrine carcinoma, for $100 million upfront and up to $1.01 billion in milestones 11. Novartis plans to apply its proprietary T-Charge manufacturing platform — designed to preserve T-cell stemness and enhance in vivo expansion — to LB2102, marking the first application of T-Charge to a solid tumor CAR-T candidate 11.

Radiopharmaceuticals (radioligand therapies) emerged as a distinct category: in January 2026, Novartis licensed a peptide-based radioligand asset from Zonsen PepLib Biotech for $50 million upfront 25, reflecting global pharma's recognition of China's peptide library technology platforms as a source of next-generation targeted radiopharmaceuticals for solid tumors.

Deal Economics: From Vendor to Co-Author Relationships

Several structural trends define how these deals have evolved. Early transactions (2021–2022) predominantly featured milestone-heavy frameworks with moderate upfronts ($80–175 million), appropriate for preclinical or early-stage assets where clinical risk remained high. As Chinese assets matured to phase II and phase III with competitive efficacy data, upfronts escalated dramatically — $800 million (BMS–SystImmune), $1.25 billion (Pfizer–3SBio), $650 million (AbbVie–RemeGen) 201323. The Merck KGaA partnership with Hengrui for HRS-1167 (a next-generation selective PARP1 [poly(ADP-ribose) polymerase 1] inhibitor) and SHR-A1904 (Claudin-18.2 ADC) for approximately $170–180 million upfront and €1.4 billion total introduced targeted small molecules alongside ADCs into the licensing mix 22.

Structurally, most deals share a consistent architecture: the Chinese licensor retains exclusive rights in Mainland China and Greater China, while the global partner receives exclusive ex-China rights. Co-development and co-commercialization options for the US (exemplified by BMS–SystImmune and BioNTech–DualityBio for DB-1311) represent a maturation of the model, granting Chinese companies operational involvement in the world's largest oncology market and participation in global revenue beyond milestone payments 208. The Innovent–Pfizer agreement of May 2026 for 12 early-stage oncology candidates ($650 million upfront, $10.5 billion total) introduced a tiered three-bucket structure: co-development/co-commercialization in the US and EU for four programs, exclusive ex-China license for four programs, and global exclusive license for four programs — a level of structural complexity that signals genuine partnership rather than asset acquisition 24.

Regulatory Validation and Clinical Data Quality

A recurring concern for global partners has been the generalizability of Chinese clinical data to Western populations. Several developments have materially addressed this. HARMONi's global phase III results for ivonescimab — with approximately 38% of participants from Western countries — demonstrated consistency with the China-only HARMONi-A results, validating data reproducibility 27. The FDA's BTD for sac-TMT signals regulatory receptivity to Chinese phase II data as a basis for US registration-enabling trials 35. The NMPA's formalized 30-day expedited clinical trial review pathway, which prioritizes globally synchronized development programs and international multi-center trials, further integrates Chinese sites into multinational phase III designs 19. Together, these regulatory and clinical developments have substantially reduced the perceived risk of investing in Chinese-origin oncology assets.

Strategic Signals: The Ecosystem Reordering

Patent cliff pressures at AstraZeneca, BMS, Pfizer, and Merck mean that internal R&D alone cannot fill pipeline gaps cost-effectively or rapidly enough 1. China's clinical trial infrastructure, novel modality leadership in ADCs and BsAbs, and R&D velocity at lower cost structures have created a compelling external innovation source. The shift from simple molecule licensing to platform access, asset swaps, technology-sharing, and co-commercialization — exemplified by BMS's May 2026 $15.2 billion strategic alliance with Hengrui covering asset exchanges, joint discovery, and shared development risk 1 — marks China's definitive emergence as a co-author of global oncology innovation rather than a supplier. For oncologists and clinical researchers, the practical implication is clear: China-origin agents are entering global clinical trials, regulatory pipelines, and, increasingly, treatment guidelines on timelines competitive with any Western-discovered therapy.

Summary Transaction Table: Major China-to-Global Oncology Licensing Deals (2021–2026)

Table notes: "Upfront Payment" reflects disclosed figures in USD unless otherwise noted. "Not disclosed" indicates information was not available in retrieved source materials. "Total Potential Value" includes upfront + milestone payments + royalty frameworks where available. "Stage at Signing" reflects development phase at deal announcement. Territory carve-outs reflect deal terms as reported; "Greater China" typically encompasses Mainland China, Hong Kong, Macau, and Taiwan.