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By Minali Nigam
Cancer has been the leading cause of the death in North Carolina since 2009, when it surpassed heart disease as the Grim Reaper’s best friend here.
Combining death rates from all types of cancer, in 2013 North Carolina saw 167.7 deaths out of 100,000 people, which is about the national average.
But there are pockets of the state where death rates are considerably higher than average, and one of the worst areas, not just in the state but in the country, is in northeast North Carolina, said Sam Cykert, UNC-Chapel Hill’s director of health and clinical informatics.
Researchers at UNC have been looking at survival outcomes for adults with one type of blood cancer called acute myeloid leukemia (AML). In a study, published in June, they found three “hotspots” associated with higher death rates from AML including parts of northeastern North Carolina, a region near Greenville, and a region in northern Wake County, extending into Durham.
“Our study wasn’t able to pick out the exact reasons for this,” said Ashley Freeman, a clinical fellow at UNC and one of the study’s authors. “But it was interesting to note that it wasn’t a simple relationship with race or income level, education level and things like that.”
“We believe this means there’s something more complex going on with the local health care structure and possibly at the provider level that’s affecting outcome for patients.”
A complex disease
Each type of cancer has its own “complex mechanisms” and can present differently from patient to patient, and even from state to state, said Andrew Olshan, the director of the epidemiology department for UNC’s Gillings School of Global Public Health.
“Different cancers have different risk factors and some are definitely driven by things that are linked with socioeconomic status and poverty,” he said, “Some cancers don’t follow that pathway.”
For example, people in geographic areas with high death rates from colorectal cancer, Olshan said, often don’t get the screening and treatment to remove the cancer, a result of inadequate access to healthcare facilities.
AML is a cancer that follows a different pathway.
“AML is a pretty rare disease so not every physician out there is going to be familiar with the treatment, diagnosis and follow-up,” said Freeman. It’s important to have specialists who know what they’re seeing.”
So it was hard to draw a straight line between the location and the reason why more people died in that place from AML, Freeman said. But the study did find one high-risk region having fewer general practitioners and radiation oncologists.
“It may be that there are less services available in those areas and may be affecting things like referrals,” to the correct specialist, she said.
North Carolina is uniquely positioned because there are three National Cancer Institute (NCI) centers, said UNC cancer epidemiology researcher Anne Marie Meyer. She was also involved with the AML study.
Meyer says some states don’t even have cancer centers. Yet, even though North Carolina has several NCI cancer centers, “we still see patients in the state who aren’t being referred.”
Part of the problem, she said, could be that doctors in rural areas are overwhelmed by diseases such as Type II diabetes, heart failure and stroke and they fail to refer patients to specialists.
“In the AML context, timing is of the essence, with regard to getting a patient diagnosed and into care and into intensive chemotherapy,” Meyer said.
According to the American Cancer Society, “this leukemia can progress quickly if not treated and would probably be fatal in a few months.”
“Some patients who have preventable and treatable cancers are missed. It’s really a function of not only demographics and [socioeconomics], but also health care infrastructure that’s available in specialty care,” Meyer said.
‘Moving the dial’
Doctors, state legislators and cancer survivors came together over the past several years to help write the North Carolina Comprehensive Cancer Control Plan for 2014 to 2020. The plan addresses ongoing healthcare needs and treatments for six different types of preventative cancers that are linked to factors such as tobacco use, poverty and health care coverage.
“When we look at breast, cervical and colon cancer, even after we control for race and poor insurance coverage, we still see inequalities that are potentially geographic in nature,” said Meyer.
“What this tells us is cancer is a complex disease,” she said.
In an effort to reduce geographic cancer disparities in the state, the cancer control plan calls for early detection through routine screenings, partnerships with transportation, employment and housing services for underserved patients, and education programs.
“We are trying to move the dial in North Carolina to lessen mortality and lessen disparities by region, by racial ethnic group, etc.,” said Olshan.
One clear intervention is screening for colorectal cancer, he said.
“It’s a tractable problem and among the most common cancer,” which is why research is targeting a more precise definition of colorectal cancer hotspots and increase screening in those areas.
People don’t have access to the services needed to get colonoscopies to more patients. “We’re not going to go in overnight and obviously reduce poverty” and other barriers to screening, Olshan said.
“We have to work with the health department, healthcare providers, a whole variety of network groups… It’s clearly a multidisciplinary approach to try and implement an intervention and spread the dissemination of a proven intervention like screening.”