GRAIL has created a liquid biopsy [blood] test called ‘Galleri’ to screen for fifty different very early cancers. Widespread use of the test could save 100,000 lives per year in the US from a cancer death at a cost of $950. Grail recommends annual screening for everyone over age fifty, plus screening for anyone at elevated risk for cancer related to genetic, environmental, or behavioral factors. That represents 100 million individuals in the US at a cost of $95 billion annually. I argue that such an expenditure should be a low priority item, not warranted for both reasons of justice and financial prudence. The cost per life saved would be $950,000. No American insurance company or European government would likely see that as ‘high value’ care, given that 99% of the tests each year would be negative.

This is a ‘wicked’ challenge because every proposed allocation would create a different mix of injustices. If these costs were simply added to the cancer budget, we risk the injustices of ‘onco-exceptionalism.’ If these costs were subtracted from the US cancer budget of $211 billion, most metastatic cancer care (targeted therapies) would have to be foregone. If family history alone determined elevated cancer risk, younger individuals at elevated risk for cancer related to complex, polygenic risk factors would be denied this screening at social expense (and risk premature death). Whole genome sequencing could identify those individuals at a one-time cost of $500 billion, still requiring identifying a risk cutoff. Imagine the complexity of identifying environmental carcinogenic risk factors significant enough to justify the Galleri test. Imagine the publicly perceived injustice of paying for Galleri for smokers and sun-worshipers. I argue that a process of rational democratic deliberation is needed to achieve ‘rough justice’ regarding the screening use of liquid biopsies.