AMA Journal of Ethics^®

In the 21st century, cancer is projected to be the single greatest killer in the world.¹ While nearly 10 million deaths due to cancer occurred globally in 2018, approximately 70% of those deaths occurred in low- and middle-income countries (LMICs),² underscoring that cancer is a reflection of global inequality. Governments will not be able to treat their way out of cancer.³ Up to half of cancers are preventable,⁴ but several issues challenge prioritizing prevention. Prevention often lacks the social visibility and market appeal of treatment and depends on sustainable behavior change. Moreover, prevention is held to a different standard than treatment; while treatment is assessed by whether it leads to a return equal to its cost, prevention is expected to produce a net positive return.⁵ Accordingly, prevention remains neglected.

This theme issue of the AMA Journal of Ethics is devoted to exploring ethical complexities of cancer prevention in LMICs. Evident disparities between cancer control programs in LMICs and in high-income countries illuminate practical challenges to reducing morbidity and mortality of individual patients and at the national level. In providing care to patients in low-resource settings, how should clinicians overcome barriers to access? Where screening services are limited, clinicians must decide whether and when a suboptimal approach is better than none.

Of risk factors for cancer, tobacco remains the leading contributor to cancer incidence worldwide.² Clinicians have an increasingly vital role in prioritizing smoking cessation in light of the rising use and market penetration of cigarettes in LMICs.⁶ The role of global tobacco control regulation, such as the World Health Organization Framework Convention on Tobacco Control,⁷ remains paramount in preventing youth from lighting their first cigarette (or e-cigarette), but its impact will depend on how it is implemented and enforced.

Cervical cancer in many LMICs is the leading cause of cancer death in women.¹ In these settings, human papillomavirus vaccination policy typically targets girls alone, but a more equitable policy might be a gender-neutral one that includes vaccinating boys to prevent male-specific cancers while reducing spread of the virus.⁸ Given health care access disparities, emerging home-based, self-sampling, cervical screening initiatives could have greater impact on cancer rates than existing facility-based approaches. As oncology research and clinical trials continue, biobanks will play an increasingly important role in deepening our understanding of complex cancer pathophysiology by serving as long-term repositories of biological material for research.⁹ Ethical issues in biobanking emerge in practice, however, and researchers must navigate informed consent processes in LMICs. Finally, examining principles of international law, particularly regarding patent protections, holds promise for identifying and addressing barriers to accelerating new developments in cancer prevention technology. This issue of the AMA Journal of Ethics examines these timely, complex ethical issues.