USA TODAY International Edition
FOUND TOO LATE: CANCER PREYS ON RURAL AMERICANS
The benefits of health screenings that can detect diseases at early stages when they can be beaten often bypass the nation’s poor and minority populations, for whom prevention is problematic
In the home of the blues, amid dying towns, gravel backroads and endless Mississippi Delta farmland, cancer grows, spreads and kills mercilessly — even the types that can be caught or stopped with wellknown screening tests.
Here, 73- year- old Ruby Huffman got her first colonoscopy only after passing blood, and it found a huge cancerous tumor. Sixty- one- year- old Rita Stiles went at least a decade without a mammogram. And 55- year- old Tina Williams has had only one Pap smear in her life.
The story is the same in many parts of America, USA TODAY has found, and experts say there’s no excuse. Screenings that have been around for decades can detect breast, colorectal and cervical cancers at early stages, and even find colon polyps and cervical lesions before they turn into cancer. But their promise is limited — the nation’s progress against cancer diminished — because poor, minority and rural residents are left behind.
USA TODAY analyzed stateby- state data on screenings, incidence and death for these three cancers. The newspaper worked with the North American Association of Central Cancer Registries to compare states’ incidence- to- mortality ratio to see where deaths exceed what’s expected based on how often cancer strikes. States faring worst include Arkansas, Mississippi and Alabama, largely because cancers were found late, causing untold suffering and pushing up health costs for everyone.
“We really can alter survival from the disease with early detection,” says Andrew Salner, director of the Hartford HealthCare Cancer Institute in Connecticut, one of several New England states that fared well. “We can bring down mortality … if we can provide equal access to care.”
But getting preventive screenings and quality treatment is much tougher for people who struggle daily just to get by. So cancer preys upon the poor. State- by- state rankings for poverty closely mirror those for cancer deaths.
While the Affordable Care Act has brought insurance coverage to millions, it hasn’t solved the myriad other problems impeding access to care, such as transportation difficulties, lack of education, inability to take time off from low- wage jobs for medical appointments, and shortages of doctors, hospitals and cancerscreening facilities. It hasn’t made all doctors “culturally competent” to effectively care for minority patients.
Though it eases financial barriers, “I don’t think the ACA is a panacea to make everything equal,” says Otis Brawley, chief medical officer for the American Cancer Society.
Government funding is no equalizer either. States with the most cancer deaths often have less money to fight the disease, so
“We really can alter survival. ... We can bring down mortality … if we can provide equal access to care.”
Andrew Salner,
Hartford HealthCare Cancer Institute
their efforts reach only a fraction of the most vulnerable citizens. Rural hospitals dependent on government insurance struggle with low reimbursement.
Meanwhile, federal funding for cancer screening is in flux. A nationwide program that has provided more than 12 million mammograms and Pap tests for low- income women since 1991 lost $ 8 million in federal funds in the last five years. And President Obama’s proposed budget for next year cuts $ 42 million from breast, cervical and colorectal cancer- screening programs on the assumption the ACA will improve access to screening. A bipartisan spending deal hasn’t yet determined specific allocations for particular programs, but previous House and Senate bills restored at least some of the money.
“The environment right now is very challenging,” says Amy Elizondo, a vice president at the National Rural Health Association. “The budget cuts in general, the hospital closures, the primary care shortages — all of that is sort of this perfect storm creating these disparities.”
And these disparities can be as deadly as cancer cells.
Ruby Huffman curls on a couch in the small house she shares with her husband Wayne, located off a miles- long gravel road running through flat acres of Arkansas maize. After being diagnosed with colon cancer in May, she’s had surgery to remove her tumor, a hysterectomy and several rounds of chemo. She travels 1.5 hours each way every two weeks for treatment.
When she was diagnosed, “the doctor asked if she ever had a colonoscopy, and she hadn’t … She told me, ‘ I don’t need one,’ ” says Wayne Huffman, a retired salvage yard worker. “If she would’ve got them when she was 50, ( what was once a polyp) might not be cancerous.”
Statewide, slightly more than half of Arkansans between 50 and 75 years old got a screening sigmoidoscopy or colonoscopy as recommended — compared with nearly three- quarters in the bestperforming states, according to 2012 federal survey data in the American Cancer Society’s latest cancer prevention report. Less screening means more death. National Cancer Institute statistics analyzed by USA TODAY show Arkansas’ mortality rate of 17.6 per 100,000 was 20% higher than the national average, even though incidence was only 7% higher.
The trend is similar for cervical and breast cancers. Just under 40% of Arkansas women 40 and older got a mammogram and clinical breast exam in the past year, for example, compared with about 60% in the best- performing states. This contributes to a death rate 9% higher than the national average even though breast cancer strikes Arkansas women at a rate 11% lower than average.
Preventing cancer is not a priority in such places, says Clifton Collier, CEO of the Lee County Cooperative Clinic in Marianna.
“When you’re living in poverty, you have more immediate problems than seeing about getting a prostate screening or, ‘ Is it time for a colonoscopy?’ ” he says. “You’re trying to make sure food is on the table. You’re trying to make sure the lights are on. So we neglect our health a lot of times.”
Public health efforts often don’t reach these vulnerable Americans. Thomas Tucker, cancer registry director in Kentucky, echoes other experts: “The U. S. has the greatest cancer control program in the world — for the middle class.”
Bill Strickland of Center Ridge, Ark., says he was told he was fine after a colonoscopy at a local hospital, which he got at age 46 after a colleague at the paper mill where he works developed colon cancer. But just a few years later, another colonoscopy detected potentially deadly Stage 3 colon cancer that required surgery and chemotherapy. “Looking back on it, maybe … these guys missed it the first time,” says Strickland, 56, who is African- American and now gets his care at UAMS. “Now I tell people: Go to a place where they specialize in doing it, like an endoscopy center.”
Wealthier states tend to be much further ahead in cancer screening and treatment — and survival.
“Every state and locality has different resources available … Rural and frontier states have always been a challenge,” says Lisa Richardson, director of the division of cancer prevention and control in the U. S. Centers for Disease Control and Prevention, which helps fund state cancer control programs. “States that look better tend to have a better health insurance system, a health care system that functions better, and more coordination.”
Connecticut is among this group, as are Vermont, Hawaii and Rhode Island.
But Salner says states without the advantages of wealth or small size can also make strides against cancer by truly understanding their unique problems, coming up with creative solutions and mustering political will.
In Kentucky, for example, a gastroenterologist started the renowned Colon Cancer Prevention Project, which raised money and awareness of the disease and pushed for programs such as free screening for low- income, uninsured residents.
“A small group of people who are committed to work on disparity issues can really get it done,” Salner says.
If disparities are allowed to fester, however, experts say America’s groundbreaking research, technological advances and new treatments will only go so far toward defeating cancer.