Two large-scale, phase III cancer prevention trials, the Breast Cancer Prevention Trial (BCPT) of tamoxifen and Prostate Cancer Prevention Trial (PCPT) of finasteride, concluded with strikingly positive and simultaneously problematic results: reduced cancer risks but a major adverse finding with each agent that prevented its widespread use in the community. For most moderate-risk people, such as those studied in the BCPT and PCPT, the benefit of reduced breast or prostate cancer does not outweigh the major risk of tamoxifen (endometrial cancer in the BCPT) or apparent risk of finasteride (high-grade prostate cancer in the PCPT). Promising interventions with biologically active substances are likely to have adverse, perhaps unforeseen effects, especially with long-term preventive use. Acceptance of such agents will depend heavily on the level of cancer risk of the target population. This article outlines research in molecularly identified high-risk oral intraepithelial neoplasia that creates the clinical opportunity for optimizing the riskbenefit ratio of agents to prevent oral cancer. Two other major research efforts focused on improving preventive agent risk-benefit ratios are molecular-targeted research designed to target away from known adverse signaling pathways and multidisciplinary research based on the PCPT that will develop comprehensive models of prostate cancer risk (especially of aggressive prostate cancer) and pharmacoecogenetic models for identifying high-risk men most likely to benefit from (and not be harmed by) finasteride or similar (5A-reductase inhibiting) agents. Defining and targeting high-risk populations, developing molecular-targeted approaches, and developing accurate pharmacoecogenetic models promise to reduce the risk of chemoprevention and ultimately to reduce the risk and burden of major cancers. (Cancer Res 2006; 66(6): 2893-903) For decades, the mantra of cancer chemoprevention has been: ''Find effective agents with relatively little or no toxicity for preventing cancer in relatively healthy people.'' In pursuing this goal, trials big and small of a myriad of agents with relatively less or more toxicity reached at least a temporary plateau with the doubleedged results of the Breast Cancer Prevention Trial (BCPT) published in 1998 (1) and Prostate Cancer Prevention Trial (PCPT) published in 2003 (2). Tamoxifen reduced the risk of breast cancer by almost 50% among the 13,388 randomized women (moderately high risk) of the BCPT but also increased these women's risk of endometrial cancer. Finasteride produced a 25% overall reduction in prostate cancer prevalence among the 18,882 randomized men (ages z55 years) of the PCPT but also surprisingly seemed to increase these men's risk of high-grade prostate cancer. Despite the established preventive effects of tamoxifen and finasteride, the important risks/side effects associated with these agents produced a widespread resistance to their use for preventing breast or prostate cancer.Important work in the same moderate-risk vein con...