Children who develop cancer in low- and middle-income countries (LMIC) have a lower chance of long-term event-free survival than their counterparts in high-income countries (HIC). Causes of excess treatment failure in LMIC include lack of diagnosis at the secondary and tertiary care level, misdiagnosis, refusal and abandonment of treatment, toxic death, and excess relapse. Each major cause of treatment failure has contributing subcauses and each of these has identified strategies to address them that have documented benefits in both LMIC and HIC. Pediatric oncology surgeons have a key role to play to improve diagnosis, risk stratification, local control, supportive care, and, ultimately, survival.