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  • Mack Carmack

Cancer Rates in Appalachian Kentucky Prove an Uphill Battle

Out of everywhere in the U.S., why is cancer in Appalachian Kentucky so abundant?

Figure 1- Photo of my grandfather hours before he passed away from lung cancer.

On March 28th, 2020, Jimmy Clifton put on his blue and grey flannel, camo hat, and sweatpants like it was any other day. He rode around the car for a few minutes with his daughter before inevitably getting tired and laid down on his hospital bed. That night he fell asleep and never woke up again. Just six months prior, Clifton had been diagnosed with Stage 3 lung cancer after doctors found a mass in his lung. He suffered his entire life from COPD and PTSD. He was a war veteran and a carpenter, and he was also my grandfather. He was just one of my family members to pass away from cancer in the Appalachian region, and his story is just like the stories of many other victims to the disease.

Rather people like to admit it or not, cancer is everywhere, and it kills daily. Although cancer appears everywhere in the United States, there is an unfathomable amount in the Eastern region of Kentucky. Out of everywhere in the United States, why is cancer in Appalachian Kentucky so abundant? Well, a lot of Appalachians are at a high risk of developing cancer, and their diagnosis is due a system that abandoned them a long time ago.

Cancer Statistics

Current statistics, in Kentucky, show that cancer affects 506.8 out of every 100,000 people. The three most common types of cancers in Kentucky are lung, colorectal, and breast cancer. The most important thing to remember: Eastern Kentucky has the highest rates of cancer out of anywhere else in the United States.

Although Kentucky houses many different cancers, lung is perhaps the most common and holds the highest burden in the state (burden meaning most expensive for treatment on the state). Stephanie Carmack (relation to author) is the current Electronic Ethnology Coordinator for the Kentucky Cancer Registry. In this position she ensures that all patient diagnoses are reported to the state and inserted into the database. She has worked the position for ten years and worked in clinical surgery for twenty. Safe to say that if there’s anyone who knows numbers about cancer, it’s Stephanie. “I would say several hundred get diagnosed every day.” Although she isn’t responsible for reporting deaths from cancer in the data base, the Kentucky Cancer Registry does keep track of that statistic.

Carmack’s colleague, Eric Durbin who directs the Cancer Registry and Cancer Informatics also serves on the faculty board of University of Kentucky’s School of Medicine. He’s been in the field of cancer research for over thirty years. Both Carmack and Durbin agree that cancer in Kentucky is slowly decreasing. That being said, with special attention to screenings in the past few years, those rates are expected to rise.

Figure 2- Photo derived from Kentucky Cancer Registry statistics page portraying KY counties with the highest incident rates.

Although rates are expected to change over time, as of 2020, 139,553 patients got diagnosed with cancer. According to the Appalachian Regional Commission and the Kentucky Cancer Registry, 20/29 counties with over 500 per 100,000 people with cancer diagnoses, are in the Appalachian Region (red counties). The most impacted counties of the bunch include Floyd, Powell, Lincoln. So, what makes Appalachia so prone to cancer? And why lung cancer out of all types?

Cigarette Smoking

Durbin attributes the leading cause to smoking and genetics, “Smoking is the is one of the primary known causes for lung cancer. So, I still believe that is a primary factor and I think it Kentucky there could also be some inherited risk factors. So, there are certain genetic inherent, you know, inherited mutations.”

However, Chris Green, Doctor and Professor of Appalachian Studies and Director of the Loyal Jones Appalachian Center, thinks otherwise. The Loyal Jones Appalachian Center (LJAC) is a museum founded by Loyal Jones, located at Berea College. Members of the LJAC conduct both qualitative and quantitative research about the Appalachian region. Green relates the causes of lung cancer to external factors like the culture that causes Appalachians to pick up smoking in the first place. “People look for solutions to stress and I think it's one of the reasons that people turn to drugs. It's one of the reasons I only drink a six pack of beer about every three months […]. But nicotine is another answer for stress, right? Nicotine is both addictive and a stress relief.” Essentially due to the burdens of growing up in the Appalachian Region where healthy food is scarce and work is hard, cigarette smoking is an easy solution. Because of nicotine’s addictive nature, many start smoking and cannot stop, ultimately leading to lung cancer down the road. “It becomes a cultural norm by having everybody needing tobacco around you. There you go. I believe that with so many counties now.”

So, with lung cancer being the most common and having the highest burden in the state, there’s not exactly one reason why, rather than a collection of misfortunes. It’s both risk factors and cultural causes. It’s an entire system. Some of the risk factors and contribution to the development of cancer is asbestos, air pollution, and black lung. Although all affect the Appalachian Region, black lung has a special contribution.


Black & White Lung

Bobby Starnes, 77, Doctor and Professor in Appalachian Studies is a coal miner’s daughter and watched her father die due to black lung. Starnes explains all coal miners will likely develop black lung in their lifetime, “Black lung has always been associated with coal mining, because when you drill into the coal or into the slate rock around the coal, it creates a dust. And you breathe in that dust, and the coal also creates a black coal dust which you also breathe in. And so, the question is not will I get black lung, it’s how soon will I get it?” Black lung inadvertently leads to cancer, but as does white lung as well. White lung is more likely now, as most coal in older coal mines is gone. Instead, silica covers the ground and breathing in its dust leads to a deadly disease called Silicosis, which also leads to lung cancer.

Green, in response to white lung, says, “Those latent carcinogens are fine when they are trapped in the rock and the rock is processed wherever, but when you suddenly released them into the environment into the drinking water through these explosions. Through these giant ponds, the billion gallon ponds they have on top of mountaintop removal sites, where there ain't nothing that can swim in that and survive and there's no way you can drink it and survive. When you are surrounded by those puddles of death, you're going to get [cancer]. It's going to happen to you.” So, in a way, white lung is more concerning that black lung and more dangerous, too. From this, oncologists and the Kentucky Cancer Registry can expect high rates of lung cancer in the future from modern coal miners.


Unhealthy Lifestyles

Eric Durbin and other experts recommend quitting smoking to reduce chances of developing cancer, as well as regular cancer screenings and a healthy lifestyle. Unfortunately, a healthy lifestyle may not be accessible for an Appalachian living in a food desert. Students at the University of Kentucky’s Appalachian Career Training in Oncology (ACTION Program) believe that an unhealthy diet can only further one’s chances of developing cancer. Traditional Appalachian foods like fried chicken, fried okra, mashed potatoes, and mac & cheese tend to be high in carbohydrates and low in protein. These food products are even more dangerous when they are cooked in oils with high fat content, like Lard or Crisco.

Green attributes the diet problem to a cultural and societal impact, “There's a lot of Appalachian foods which are, you know, bacon key. I love some bacon, right? I'm pigs and biscuits, [and] that is not the most wholesome food either, in the long run. But that food was developed at a time that people had to have great stamina and eating it because of work on the land.” Although working conditions may have changed in the last twenty years, access to healthy foods isn’t necessarily an easy feat. Most Appalachians living in food deserts result to boxed foods or nonperishables like soups, Kraft Mac & Cheese, and Hamburger Helper. These food products only increase one’s likelihood for developing cancer, “I think what that what makes it unhealthy is not in itself, but our body needs. The structures of both the vitamins and the complex carbohydrates, and without those complex carbohydrates, our metabolisms don't work as well. And right, people are just surviving, If you don't have the options to survive, you survive as you do, but there are consequences to that,” said Green.

Some other risk factors in developing cancer are age, race, socioeconomic status, low literacy and low levels of education. Eric Durbin explains these circumstances are what leads Appalachian Kentucky to its cancer susceptibility, “The Appalachian region of Kentucky is often characterized, unfortunately by low literacy, and high poverty. Poverty is a risk factor for cancer any place in the world. So, any place where you have people that don't have a lot of resources or education and that sort of thing. It just leads to poor health behaviors, which in turn leads to susceptibility to cancer and you can see that across the globe, but within the United States, you're exactly right. The rates are really the very highest in Kentucky.”


Additional Risk Factors

So, although smoking is likely attributed to the development of lung cancer, there is a multitude of other reasons one may develop the disease. A lot of the time, the people of Appalachia are working against hundreds of risk factors that make them prone to developing cancer. For instance, up until the early 2000s, asbestos was still used in Appalachian house building due to its cheap nature and accessibility. This is just one of many examples of the lives Appalachians are fighting. With all of these risk factors working against each other, cancer is likely to affect anyone in the Appalachian Region, especially Kentucky.

But cancer is much more than words on a page and statistics. Cancer kills. Cancer tears families a part. Cancer is everywhere. Currently, over a million Appalachians are at risk for developing cancer. Most currently impacted at Floyd county at risk with 179,000 individuals at risk, with Powell county close behind at 61,400. Not to mention, these counties are known for their rich coal and fattening foods.

Every person reading this article most likely has lost someone due to cancer. It’s important to remember it isn’t their fault. It wasn’t the cigarettes they smoked, their unhealthy lifestyle, or the doctors’ appointments they neglected to make. Rather, it was a system constructed against them from the beginning that Appalachian people have been fighting against for hundreds of years.

When Bobby Starnes told me she was diagnosed with breast cancer, the first place she wanted to go, was back to Knott county, and wash her toes in the creek water. “I need to go home, stand in Caney Creek, and let the water rush over my feet. And it will wash this evil out of my body.” Starnes has been in remission for several months now, but her cancer diagnosis ensued years of trauma, both physically and emotionally.

Figure 3- Photo of my grandmother and her siblings, all of whom were diagnosed with either cancer or COPD.

Although no one with cancer is “lucky,” some are more fortunate than others. Some people suffer for a long amount of time with cancer and live to tell the tale, and some are diagnosed shortly before their death. That was the case of my grandma, an unlucky one. She was diagnosed with cancer in July of 2023, before dying a short month later. For those thirty days, she sat reclined on her couch, her inhaler and breathing treatment on the end table beside her. Her body began to turn cold and purple, and in her last moments, she missed Appalachia. While she lied on her death bed, my mother whispered in her ear as she took her last few slow breaths, “Imagine you’re on the beach right now, and it’s warm and sunny.”

“No,” she said. “I wish to be in the mountains.” So, although the Appalachian mountains may be filled with cigarettes, radioactive and toxic chemicals, it’s a home and refuge for many.

Learn more about cancer in Kentucky by visiting the Kentucky Cancer Registry or by reviewing current cancer statistics.

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