The Scope of Care: Who Gets Looked At, and Who Gets Overlooked

A 45-year-old woman in Seoul receives a reminder that her biennial endoscopy is due. The procedure is quick and inexpensive, covered by national insurance. It’s about as routine as a dental cleaning. A 45-year-old Korean American woman in Durham, however, whose stomach cancer risk is many times the US average, will likely never be offered one unless she develops major symptoms. 

This difference is in the design of the health system she lives in. South Korea built its screenings around the diseases its population actually gets. The United States, however, built its guidelines around an “average” patient, and for many diseases like stomach cancer, that average hides a lot of the people who are most at risk. This gap raises an important ethical question for the American healthcare system: should American healthcare account for where patients and their families come from, and can it do this without going back into race-based medicine?

Stomach cancer is one of the most common cancers in Eastern Asian countries, and South Korea has treated it that way. Since 1999, its National Cancer Screening Program has offered adults over the age of 40 an upper endoscopy every two years. In a nationwide study that analyzed this program, people who had been screened had approximately 21% lower odds of dying from stomach cancer than those who had not. Among those screened three or more times, the odds were significantly lower, at 81% [1]. This is because most tumors are found early, meaning many can be removed through the endoscope itself, without any major surgery or risks.

The American approach looks very different. Screening for stomach cancer is not a part of routine preventive care, so upper endoscopies usually only happen after a patient reports pain or other symptoms. By then the disease has often advanced. Once the cancer reaches distant organs, five-year survival rates are just 8% [2].

For many Americans, waiting for symptoms to show is reasonable because their risk is low. However, California registry data show that every non-white group had higher rates of stomach cancer than non-Hispanic white adults. Specifically, Korean Americans over 50 had about 13 times the rate of a non-Hispanic white adult [3].

Changing the way US screenings work would make prevention fairer, but it also raises a concern. Guidelines designed for the average patient exclude the groups with the highest risks, so adjusting for these groups seems fair. However, doctors have recently stopped using race in a lot of their medical formulas because race assumptions rested on weak evidence that often led to worse care for minority patients. 

The solution here is to screen based on the actual causes and not the race. Stomach cancer risk comes mainly from H. pylori infection, so being born in a high-risk country or having a family history could directly lead to stomach cancer later in life. In 2025, the American Gastroenterological Association stated that screenings should be considered for people with these risk factors, including first-generation immigrants from high-risk regions [4]. However, this advice is not an official guideline, so insurance companies do not have to cover the tests. As a result, whether a high-risk patient gets screened still depends on their socioeconomic status and whether their doctor knows about it.

Because America is such a diverse place, doctors should understand the health risks patients carry from their home countries. The USA does not need to copy Korea’s program. Instead, it could be more mindful of where patients were born, offer H. pylori testing and preventative screenings for higher-risk patients, and fund the research needed to establish an official screening guideline. America’s patients come from all over the world, and its approach to prevention should reflect that.

Reviewed by: Aman Maredia

References

[1] Jun, J. K., Choi, K. S., Lee, H. Y., Suh, M., Park, B., Song, S. H., Jung, K. W., Lee, C. W., Choi, I. J., Park, E. C., & Lee, D. (2017). Effectiveness of the Korean National Cancer Screening Program in Reducing Gastric Cancer Mortality. Gastroenterology, 152(6), 1319–1328.e7. https://doi.org/10.1053/j.gastro.2017.01.029.

[2] National Cancer Institute. (2018). Stomach cancer - cancer stat facts. SEER. https://seer.cancer.gov/statfacts/html/stomach.html.

[3] Shah, S. C., McKinley, M., Gupta, S., Peek, R. M., Jr, Martinez, M. E., & Gomez, S. L. (2020). Population-Based Analysis of Differences in Gastric Cancer Incidence Among Races and Ethnicities in Individuals Age 50 Years and Older. Gastroenterology, 159(5), 1705–1714.e2. https://doi.org/10.1053/j.gastro.2020.07.049.

[4] Shah, S. C., Wang, A. Y., Wallace, M. B., & Hwang, J. H. (2025). AGA Clinical Practice Update on Screening and Surveillance in Individuals at Increased Risk for Gastric Cancer in the United States: Expert Review. Gastroenterology, 168(2), 405–416.e1. https://doi.org/10.1053/j.gastro.2024.11.001.