Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (D.T.M., I.L.).
Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands, and School of Economics, University College Dublin, Dublin, Ireland (J.F.O.).
Ann Intern Med. 2024 Sep;177(9):1259-1264. doi: 10.7326/M24-0377. Epub 2024 Aug 6.
Racial and ethnic disparities in incidence and mortality are well documented for many types of cancer. As a result, there is understandable policy and clinical interest in race- and ethnicity-based clinical screening guidelines to address cancer health disparities. Despite the theoretical benefits, such proposals do not typically address associated ethical considerations. Using the examples of gastric cancer and esophageal adenocarcinoma, which have demonstrated disparities according to race and ethnicity, this article examines relevant ethical arguments in considering screening based on race and ethnicity. Race- and ethnicity-based clinical preventive care services have the potential to improve the balance of harms and benefits of screening. As a result, programs focused on high-risk racial or ethnic groups could offer a practical alternative to screening the general population, in which the screening yield may be too low to demonstrate sufficient effectiveness. However, designing screening according to socially based categorizations such as race or ethnicity is controversial and has the potential for intersectional stigma related to social identity or other structurally mediated environmental factors. Other ethical considerations include miscategorization, unintended negative effects on health disparities, disregard for underlying risk factors, and the psychological costs of being assigned higher risk. Given the ethical considerations, the practical application of race and ethnicity in cancer screening is most relevant in multicultural countries if and only if alternative proxies are not available. Even in those instances, policymakers and clinicians should carefully address the ethical considerations within the historical and cultural context of the intended population. Further research on alternative proxies, such as social determinants of health and culturally based characteristics, could provide more adequate factors for risk stratification.
种族和民族差异在许多类型的癌症的发病率和死亡率中都有详细记录。因此，基于种族和民族的临床筛查指南在解决癌症健康差异方面存在政策和临床方面的合理关注。尽管存在理论上的好处，但这些提议通常没有解决相关的伦理考虑。本文以胃癌和食管腺癌为例，这些癌症根据种族和民族存在差异，考察了在考虑基于种族和民族的筛查时相关的伦理论点。基于种族和民族的临床预防保健服务有可能改善筛查的危害和收益之间的平衡。因此，针对高风险种族或族裔群体的项目可以提供一种替代方案，而不是对一般人群进行筛查，因为在一般人群中，筛查的效果可能太低，无法证明其足够有效。然而，根据种族或族裔等社会分类来设计筛查是有争议的，并且有可能与社会认同或其他结构介导的环境因素有关的交叉污名。其他伦理考虑因素包括分类错误、对健康差异的意外负面影响、对潜在风险因素的忽视以及被分配更高风险的心理成本。鉴于这些伦理考虑，如果没有其他替代方法，种族和民族在癌症筛查中的实际应用在多元文化国家中是最相关的。即使在这些情况下，政策制定者和临床医生也应该在目标人群的历史和文化背景下仔细考虑伦理考虑因素。关于替代方法的进一步研究，如健康的社会决定因素和基于文化的特征，可以为风险分层提供更合适的因素。
