Cancer car e in the USA is highly technologically advanced. Personalized cancer care using molecular diagnostics to guide therapy is now the standard for patients with hematological malignancies, such as lymphoma and leukemia, as well as cancers originating in the breast, lung, colon, and other sites [1]. Personalized, high-tech medicine is expensive. US citizens spend far more per capita on medical technology, such as expensive imaging techniques and intensive care, than citizens of any other country [2]. The USA spends over 17 % of its gross domestic product (GDP) on health care, as compared to other countries in the Organization for Economic Development and Cooperation (OEDC), which spend approximately 8–9 % GDP [3]. Despite spending more, Americans have a life expectancy that is approximately 4 years less than that of citizens of other developed nations [4]. The US cancer burden is projected to increase substantially in future years due to the burgeoning older population, infectious diseases that transmit cancer-causing viruses and other pathogens, and an obesity epidemic. For instance, the population of Texas, the state in which MD Anderson Cancer Center is located, is projected to increase to 29 million in 2030 and to 32 million by 2040 (Texas Data Center and Office of the State Demographer, 2012, Migration Scenario for 2010–2050 in 1-year increments). Texans 65 or older likely will make up 21 % of the state’s population by 2050, compared to 12 % in 2014 (Texas Data Center and Office of the State Demographer, 2012. Age, Sex, and Race/Ethnicity Population by Migration Scenario).

Personalized cancer care is much more than just molecular and high-tech medicine. Another important aspect of personalized cancer care is palliative and supportive care integrated throughout the illness trajectory, especially as end-of-life approaches. Cancer care near the end of life should be person centered, family oriented, and evidence based. Education of US health professionals who provide care to people nearing the end of life has improved substantially in the past two decades, and the clinical fields of hospice and palliative care have become more established. Nonetheless, the number of specialists in these fields is too small, and too few clinicians in primary and specialty fields that entail caring for individuals with advanced serious illnesses are proficient in basic palliative care. Availability of palliative care services has not kept pace with the growing demand. Clinicians are often reluctant to have honest and direct conversations with patients and families about end-of-life issues. Patients and families face additional difficulties presented by the health care system itself, which does not provide adequate financial or organizational support for the kinds of health care and social services that might truly make a difference to them [5].

In addition, significant disparities exist in the US health care, since many Americans are either uninsured or underinsured. The Affordable Care Act (ACA) was passed by congress and signed by President Obama in March 2010 with the intention of reducing health disparities and ultimately making health care more affordable. However, the ACA remains politically charged, and debate continues regarding how best to reform the American health care system to optimize clinical outcomes and cost-effectiveness [6].

Many undocumented immigrants who are neither citizens nor permanent residents seek health care in the USA. The vast majority of these immigrants come from Latin America, primarily Mexico and the northern triangle of Central America, namely El Salvador, Honduras, and Guatemala. Many are unaccompanied minors. Drug violence, lack of economic opportunity, and poor access to health care have driven massive Latin American migration in recent years. In addition, the worldwide economic recession of 2008 caused many US residents, both citizens and noncitizens of all ethnic backgrounds, to lose private health insurance and seek care in safety net systems. An estimated 5.7 million Texans—22.5 % of the state’s population—lack health insurance, the highest percentage of uninsured citizens in the country (U.S. Census Bureau, 2012 American Community Survey). An estimated 17.9 % of Texans have incomes below the federal poverty level (U.S. Census Bureau, Small Area Income and Poverty Estimates, 2012). Indigent patients are much less likely to seek preventive services. Economic hardship and the recent wave of immigration from Latin America have therefore resulted in a much higher incidence of preventable cancers, such as cervical cancer, and a shift toward higher stage cancers.