Most Children With Cancer Live in Countries With Armed Conflict

More than half of all pediatric cancer deaths worldwide occur in regions of armed conflict, according to a new study – a finding that researchers say underscores a need to address the unique challenges of treating cancer in environments plagued by conflict and instability.

The study, led by global health researchers at Duke and St. Jude Children’s Research Hospital, analyzed cancer cases and outcomes among children living in countries affected by conflict across three decades. The researchers found that while the incidence of childhood cancer is consistent globally, disruption to timely diagnosis and treatment leads to significantly higher mortality in conflict-affected countries. 

Just over half of all children diagnosed with cancer between 1990 and 2019 lived in countries experiencing armed conflict, according to the study, which appears in the April issue of The Lancet Oncology. However, those same countries accounted for more than 60 percent of childhood cancer deaths during the study period. 

“Children are a vulnerable population that often get caught up in conflicts, not of their own fault or doing,” says Emily Smith, Ph.D., an assistant professor with the Duke Global Health Institute and the study’s co-lead author. “Our study shows that protecting them, particularly the most vulnerable with acute health conditions that require strong health systems, like cancer, is critical given the growing mortality rates in countries with conflict.”

Armed conflict can cause disruptions to health systems that impact care well beyond active conflict zones, the authors note. During periods of conflict, hospitals may be damaged or destroyed, health care workers may be displaced, and vital medications often become scarce. All of these factors contribute to delays in diagnosis and treatment of conditions such as cancer, where timely action is a significant factor in survival rates. 

In stable, high-resource settings, around 85 percent of children diagnosed with cancer survive, notes co-senior author Asya Agulnik, MD, MPH, director of the St. Jude Global Critical Care program. Countries experiencing armed conflict had an average mortality rate 20-30% higher than non-conflict countries.

“The burden of pediatric cancer is disproportionately shifted not only to low-income countries but also countries in conflict,” says Agulnik, who notes that the proportion of childhood cancer cases and deaths in conflict zones has increased over time. 

The researchers say novel interventions are needed to help countries address the complex health needs of children with cancer who live in areas affected by conflict. They advocate dedicated resources to train local providers and build the resilience of health systems in conflict zones, as well as increased collaboration with the broader healthcare community. 

“Our study found that even low levels of conflict detrimentally affect children’s cancer outcomes in those countries. We have to pay attention to not only the high levels of conflict picked up in the news, but also the smaller, more chronic levels of instability and conflict countries face when it comes to caring for children with cancer,” says Smith, who is part of the Global Emergency Medicine Innovation and Implementation Research (GEMINI) Center and the Center for Global Surgery and Health Equity at DGHI.

Smith and colleagues at St. Jude have designed a project to help address some of those challenges. Their plan would connect children with cancer in 10 low- and middle-income countries with patient navigators to help them stay on track with cancer treatments, as well as providing access to St. Jude’s global network of clinics and financial support for medications. The project was announced at the 2025 Clinton Global Initiative, and the researchers are seeking funding to enroll 5,000 families in its first phase.

DGHI professor Henry Rice, M.D., and MS-GH alumna Pamela Espinoza, now a DGHI research assistant, were co-authors on the Lancet study, which also included researchers from Stanford University, the University Medical Center Freiburg, and the University of Washington.