Investigators have found that although fewer patients may be diagnosed with and dying from cancer in Appalachia, cancer incidence and mortality rates remain substantially higher compared with elsewhere in the United States, according to a recent study published by Burus et al in the Journal of the American College of Surgeons. The findings provided the most up-to-date cancer data from the Appalachian region and included in-depth analyses within Appalachia by county.
Background
The Appalachian region—which consists of 423 counties spanning 13 states along the eastern seaboard from Mississippi to southern New York—includes a population of more than 26 million. The region has faced considerable disparities in cancer rates in recent decades; however, prior research has not focused on granular data at the county level.
“The Appalachian region is so large, so to view it as monolithic, I think is shortsighted,” noted lead study author Todd Burus, MAS, a data scientist at the Markey Cancer Center at the University of Kentucky. “The experiences of [individuals] living in different regions of Appalachia, particularly in the coal mining areas of eastern Kentucky or West Virginia, are vastly different than [they are] for individuals in other places. With this research, we sought to understand those unique regional differences to learn how we can better improve cancer screening and treatment strategies.”
Study Methods and Results
Investigators used data from the U.S. Census Bureau, the U.S. Cancer Statistics Incidence Analytics Database, and the National Center for Health Statistics to examine cancer incidence and mortality rates from 2017 to 2021 and overall cancer trends between 2004 and 2021 in the region.
From 2017 to 2021, individuals residing in the Appalachian region were 5.6% more likely to be diagnosed with cancer and 12.8% more likely to die from cancer compared with those residing outside of the Appalachian region. Despite having improved screening rates, more patients still experience mortality related to cancers that can be detected early with routine screening—including breast, colorectal, cervical, and lung cancers—in Appalachia compared with other U.S. regions.
Within Appalachia, the Central subregion—predominately eastern Kentucky, with parts of Virginia, Tennessee, and West Virginia—had the highest rates of cancer incidence and mortality, highlighting the need to increase outreach and research in these areas to better understand and reduce cancer-related disparities.
Between 2004 and 2021, the number of patients diagnosed with hepatic and intrahepatic bile duct cancers increased in Appalachia by about 3.77% per year—nearly twice the rate of hepatic and intrahepatic bile duct cancers incidence outside of the Appalachian region. These cancers are associated with chronic hepatitis C, which is associated with intravenous drug use. Rates of late-stage cervical cancer incidence, most often caused by the human papillomavirus (HPV) and largely preventable with routine screening and vaccination, also increased by 0.51% per year in the Appalachian region while remaining static in other parts of the United States.
The overall rates of cancer incidence (–0.33%) and mortality (–1.39%) may be declining in Appalachia, but they aren’t declining as fast as areas outside of Appalachia—which have demonstrated declines of 0.55% in cancer incidence from 2004 to 2021 and 1.67% in cancer-related mortality from 2004 to 2020.
Conclusions
The investigators suggested that the reasons behind these disparities may be complex, stemming from limited access to care in rural regions, historical occupational risks from coal mining and other hazardous industries, and higher poverty rates. Other factors such as a higher prevalence of obesity, smoking status, and lower HPV vaccination rates may also contribute to the widening disparities. Although the disparities are concerning, efforts can be made to close these gaps and improve care.
“From a clinical standpoint, it’s important for us to understand the differences in cancer care and overall rates depending upon the region of Appalachia,” indicated senior study author B. Mark Evers, MD, FACS, Director of the Markey Cancer Center. “Being able to understand where these disparities exist at the county level within Appalachia allows us to better focus our screening techniques and prevention strategies.”
For instance, recent public health initiatives have helped boost lung cancer screening rates in Kentucky above the national average for at-risk patients. Lung cancer–related mortality rates in Appalachia have dropped by 2.5%, and late-stage lung cancer rates have decreased by about 2.2%, with the largest period of decline associated with the advent of lung cancer screening recommendations from the U.S. Preventive Services Task Force. The investigators underscored that these positive trends demonstrated the influence that public health campaigns and targeted interventions can have on at-risk populations.
“There are reasons for hope and opportunities to increase access to preventive care in at-risk populations throughout Appalachia, especially as we learn from this data where to focus on some of these problems that have been persistent for decades,” Dr. Evers concluded.
Disclosure: For full disclosures of the study authors, visit journals.lww.com.
