The geography of cancer: Early detection, access to care lead to drop in mortality rates
GRAND FORKS — As Laminda Murach settles into a comfy recliner in a small room at the Cancer Center of North Dakota in Grand Forks, she's smiling, talkative and cheerful.
The Buxton, N.D., woman is ready for an immunotherapy treatment for metastatic lung cancer, a diagnosis she received four years ago.
"I feel good," she says. "I don't let cancer get me down."
She's a motivated grandmother.
"I've got little grandkids and great-grandkids," Murach said. "I'd like to see them grow."
"She's a tough lady," says her oncologist, Dr. Anil Potti, with a smile.
In the past, a diagnosis such as hers "usually would mean a nine-month survival rate," he said, but immunotherapy, a relatively new type of cancer treatment, has changed that.
More than a "tough lady," she's an example of the role that geography plays in the rate of cancer deaths in this country. Factors such as where you live and access to health care affect cancer outcomes.
Thanks to early detection and advances in treatment methods, such as Murach received, cancer death rates are going down. But, geographically, they vary widely — and in some parts of the country, they're actually increasing, a recent study by researchers at the University of Washington has found.
In parts of the country that are relatively poor and have higher rates of obesity and smoking, cancer death rates increased nearly 50 percent, while in wealthier pockets of the country death rates fell by nearly half, according to the UW study.
American Indians have higher rates of cancer incidence and mortality compared with the general population, according to U.S. Census data.
In North Dakota, American Indians' median household income is about half that of the state's population overall, the U.S. Census reported. Tobacco use among American Indians in the state is more than double that of the state's general population, which may explain an incidence rate of lung cancer among American Indians that's roughly twice that of the other citizens in the state.
The UW study found that Rolette County in north-central North Dakota, which fully contains the geographically remote Turtle Mountain Indian Reservation, was one of only two counties in the state to see an increase in the cancer death rate — 7.45 percent from 1980 to 2014. The other was Nelson County, where the rate increased 0.37 percent.
In that time frame, North Dakota counties with the sharpest drop in cancer death rates were Cavalier, 28.06 percent; Steele, 26.63 percent, and Sheridan, 25.72 percent.
For the time period 2010 to 2014, North Dakota's cancer death rate was about 154 per 100,000, compared with the national rate of 166 per 100,000, according to the CDC.
In 2014, in Sioux County, home of the Standing Rock Indian Reservation, the cancer death rate was 240 per 100,000; and in Rolette County, the rate was 266 per 100,000. Grand Forks County's rate was 189.
Over the five-year period ending in 2012, Minnesota's cancer death rate was 164 per 100,000.
Across the nation, in counties with the highest 2014 cancer death rates, six of the top 10 were in eastern Kentucky, the UW study revealed. Six of the lowest rates were in the Colorado Rockies.
Access to health care services "is probably not the only reason" for higher cancer death rates across the country, Potti said, "but it's the primary reason."
Cancer deaths down
"For almost all cancers, death rates have gone down (nationwide), except for pancreatic cancer — that's the only cancer (for which) death rates are actually climbing," said Dr. Anu Gaba, medical oncologist and director of the Sanford Roger Maris Cancer Center in Fargo.
"Chemotherapies are not effective for pancreatic cancer."
Overall, North Dakota's cancer death rates are in line with national rates, although that was not always true, Gaba said. "Nine or 10 years ago, our death rates were higher."
In North Dakota, lung, colon and prostate cancer account for the highest death rates in men, according to the CDC.
The state has a higher incidence rate — or, number of people diagnosed — of colorectal cancer than the national average, Gaba said.
"In men, we have the third-highest incidence rate, and in women, we're seventh-highest in the country," she said.
Regarding lung cancer in men, the state's death rate is higher than the national rate, and accounts for more deaths than the next four-highest cancers combined, CDC figures show.
In North Dakota women, cancers of the breast, lung and colon account for the highest cancer death rates.
In Minnesota, the three most deadly cancers are lung, colon and breast, followed closely by pancreas, according to the Minnesota Center for Health Statistics.
Cancer became the leading cause of death in Minnesota in 2000, the state's health department reported. In 2012, 26 percent more Minnesotans died from cancer than from the second-leading cause of death, heart disease.
Those who study health statistics are encouraged by bright spots that suggest progress is being made in the fight against cancer.
"In North Dakota there has been a statistically significant drop in cancer death rates due to female breast cancer from the time period 2010 to 2014 compared to the time period 2005 to 2009, which is very encouraging news," said Dr. Cristina Oancea, lead epidemiologist for the North Dakota Statewide Cancer Registry.
From 2010 to 2014, North Dakota's breast cancer death rate of 17.8 per 100,000, compares favorably with the U.S. rate, 21.2 per 100,000, she said.
In terms of breast cancer survival rates, "North Dakota is doing significantly better than the country (as a whole)," she said.
In Grand Forks County, death rates due to prostate cancer have dropped from 32.1 per 100,000 from 2005 to 2009 to 13.0 from 2010 to 2014, Oancea said.
Availability of services
In North Dakota, cancer death rates are probably linked to the availability of colonoscopies and cancer screening, Gaba said.
For example, "(with colonoscopy) we can find and catch polyps before they become cancerous," she said. "That's not happening to the extent it should."
Cancer death rates and the number of cancer cases could drop further if people were more proactive about their health care, Potti said.
"They may put off screening or doctor appointments because they're busy working," he said.
At his clinic, the number of patient visits dips significantly when farming activity peaks each year.
"The best way to treat cancer is to catch it early and prevent it," he said. "Time is definitely not our friend."
During National Lung Cancer Awareness Week each year, the Cancer Center of North Dakota offers free lung cancer screening to encourage people to get screened, Potti said.
"We routinely pick up early stage lung cancer, in people who wouldn't have come in otherwise," he said.
Murach was one of them.
Advances in treatment options have prolonged lives and helped to push cancer death rates down, experts say.
One of the most promising developments to emerge in recent years, immunotherapy, is still in the early stages, Gaba said.
"It is a relatively new approach, but the results have been quite remarkable," she said. "It's been an outstanding development in the last two years."
Immunotherapy targets certain "receptors on cells and pathways," said Gaba, and has been shown to be effective "especially in melanoma — cancer of the skin — and lung and kidney cancer, and some lymphomas."
"Advances in immunotherapy in the past four or five years have paid off immensely," Potti said.
The secret to its effectiveness is the use of genetic and genomic testing to create a drug treatment that's tailored to the individual patient.
Immunotherapy represents "a whole paradigm shift," he said. "It revs up the person's own immune system. It's a little bit more of a 'smart bomb.'"
The targeted approach uses drugs that a patient, based on his or her genetic profile, is known to be more sensitive to.
"It's like, Tylenol may work well for you, but Motrin may work better for me—they are both painkillers," he said.
In contrast, chemotherapy is "a shotgun approach," that kills normal along with diseased cells and, because it introduces "poison" into the system, can cause sickening side effects, he said.
"Immunotherapy is far more effective and, in most cases, better tolerated by the patient," Potti said. "(With this treatment) the patient can live longer and with better quality."
The day is approaching when cancer will "be treated as a chronic disease, in the same way that people live with diabetes."
Percentage change in cancer death rates from 1980 to 2014 in northeast North Dakota counties:
• Bottineau: Down 16.0.
• Cavalier: Down 28.06.
• Grand Forks: Down 9.58.
• Nelson: Up 0.37.
• Pembina: Down 22.57.
• Ramsey: Down 9.86.
• Rolette: Up 7.45.
• Steele: Down 26.63.
• Towner: Down 11.35.
• Traill: Down 14.93.
• Walsh: Down 14.94.
Northwest Minnesota counties:
• Beltrami: Down 6.23
• Kittson: Down 13.98
• Lake of the Woods: Down 15.03.
• Marshall: Down 20.11.
• Pennington: Up 0.02.
• Polk: Down 5.11.
• Red Lake: Down 6.38.
• Roseau: Down 21.88.
Source: Centers for Disease Control and Prevention
Common N.D. cancers
Ten most common cancers (ranked highest to lowest) in North Dakota females in 2013:
• Female breast
• Lung and bronchus
• Colon and rectum
• Melanomas of the skin
• Corpus and uterus
• Non-Hodgkin lymphoma
• Kidney and renal pelvis
Ten most deadly cancers for North Dakota males in 2013 (ranked in order of most to least deadly):
• Lung and bronchus
• Colon and rectum
• Brain and other nervous system
• Non-Hodgkin Lymphoma
• Liver and intrahepatic bile duct
• Urinary bladder
Source: Centers for Disease Control and Prevention
Cancer deaths in Minn.
Number of cancer deaths in Minnesota for both men and women in 2012:
• Lung and bronchus (2,332)
• Colon and rectum (798)
• Breast (609)
• Pancreas (600)
• Prostate (471)
• Leukemia (439)
• Non-Hodgkin lymphoma (429)
• Liver and intrahepatic bile duct (339)
• Esophagus (280)
• Brain and other nervous system (273)
Source: Minnesota Center for Health Statistics