Key Takeaways:
- Appalachia is not uniform: There are important distinctions in cancer diagnoses and deaths among different regions of Appalachia, with certain areas of Central Appalachia experiencing the highest rates of cancer incidence and deaths among the greater Appalachian region.
- Higher death rates from cancers that can be caught early with screening: Although the region has improved in screening rates, people in Appalachia still die more frequently from cancers that can be caught early with routine screening than elsewhere in the United States.
- Reason for hope: Research can pave the way for targeted interventions that can reduce these disparities, the authors said.
CHICAGO: Fewer people than before are being diagnosed with and dying from cancer in Appalachia, but cancer incidence and death rates remain substantially higher, especially in certain areas of Central Appalachia, compared to elsewhere in the U.S.
The findings, published in the Journal of the American College of Surgeons (JACS), reflect the most up-to-date cancer data from the Appalachian region and include in-depth analyses within Appalachia by county.
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. Abundant in rich folk culture and natural scenery, the region unfortunately also has faced considerable disparities in cancer rates in recent decades. But past research has not focused on granular data at the county level, the authors said.
“The Appalachian region is so large, so to view it as monolithic I think is shortsighted,” said Todd Burus, MAS, a data scientist at the Markey Cancer Center of the University of Kentucky and first author of the JACS study. “The experiences of people living in different regions of Appalachia, particularly in the coal mining areas of eastern Kentucky or West Virginia, are vastly different than it is 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.”
Some Progress, but Not Enough
Using data from the U.S. Census Bureau, the U.S. Cancer Statistics Incidence Analytics Database, and the National Center for Health Statistics, the authors examined cancer incidence and death rates from 2017 to 2021 and overall cancer trends between 2004 and 2021. Some of their main findings were:
- Greater risk of cancer: From 2017 to 2021, people living in the Appalachian region were 5.6% more likely to be diagnosed with cancer and 12.8% more likely to die from cancer compared to those living outside the Appalachian region.
- Higher death rates from cancers that are routinely screened: Although the region has improved in screening rates, more people still die of cancers that can be caught early with routine screening (breast, colorectal, cervical, and lung) in Appalachia compared to other U.S. regions outside of Appalachia.
- Variations between Appalachian subregions: Within Appalachia, the Central subregion — predominately eastern Kentucky with parts of Virginia, Tennessee, and West Virginia — had the highest rates of cancer incidence and deaths, highlighting the need to increase outreach and research in these areas to better understand and reduce these disparities, researchers said.
- Concerning upticks in liver and late-stage cervical cancers: Between 2004 and 2021, the number of people diagnosed with liver and intrahepatic bile duct cancers dramatically increased in Appalachia — by about 3.77% per year, which is almost twice as fast as outside of the Appalachian region. These cancers are associated with chronic hepatitis C, a liver disease associated with intravenous drug use. Rates of late-stage cervical cancer incidence, which is most often caused by the human papillomavirus (HPV) and is 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 U.S.
- Some progress, but not enough: Overall rates of cancer incidence (-0.33%) and deaths (-1.39%) are decreasing in Appalachia, but they aren’t declining as fast as areas outside of Appalachia. In regions outside of Appalachia, cancer incidence rates decreased by 55% from 2004 to 2021 and death rates decreased by 1.67% from 2004 to 2020.
Targeted Strategies Can Improve Care
Reasons for these disparities are complex, stemming from limited access to care in rural regions, historical occupational risks from coal mining and other hazardous industries, and higher poverty rates, the authors noted. Other factors, such as higher prevalence of obesity, smoking, and lower HPV vaccination rates, also likely contribute to the widening disparities. Although the disparities are concerning, great strides can be made to close these gaps and improve care, they added.
“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,” said B. Mark Evers, MD, FACS, senior author of the study and 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.”
Dr. Evers cited recent public health initiatives that helped boost lung cancer screening rates in Kentucky above the national average for at-risk patients. Lung cancer death rates in Appalachia are down by 2.5%, and late-stage lung cancer rates are down 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, according to the JACS paper. These positive trends demonstrate the influence that public health campaigns and targeted interventions can have on at-risk populations, Dr. Evers added.
“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 said.
Study coauthors with Dr. Evers and Mr. Burus are: Pamela C. Hull, PhD; Krystle A. Lang Kuhs, PhD, MPH; Tianyan Gao, PhD; and Christine F. Brainson, PhD.
This study was published as an article in press on the JACS website and presented at the Southern Surgical Association 136th Annual Meeting in Palm Beach, Florida, December 2024.
Disclosure: No disclosures.
Citation: Burus T, Hull P, Lang Kuhs K, et al. Examining Geographic Disparity: Variation in Cancer Outcomes within Appalachia. Journal of the American College of Surgeons, 2025. DOI: 10.1097/XCS.0000000000001273
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