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Melanie Cole (Host):  Rural Appalachia is home to an underserved population with limited access to medical care, and cancer deaths in this region have gone from being the lowest in the US to the highest. My guest today is Dr. Aron Yao. He's an assistant professor in public health science at the University of Virginia, School of Medicine. Welcome to the show, Dr. Yao, what does your research tell us about the prevalence of cancer death in Appalachia?

Dr. Aron Yao (Guest):  Just like the introduction, it was the lowest death rates in the country and now it is the highest. Cancer deaths really started to decline in early ‘90s all over the country but much lower in Appalachia, unfortunately. It's not just about the mortality rates, when we look at incidence, we look at stage of diagnosis, and we look at their survivorship care. We just saw distracting and very disturbing results that they actually have disparities across the continuum of cancer care from the incidence, early diagnosis to survivorship, all the way to mortality.

Melanie:  Before we talk about the disparities and some of your theories on the reasons for those, what types of cancer have the highest death rate in the area? What are we talking about?

Dr. Yao:  We include all cancer sites but for rural Appalachia, you can imagine, lung cancer death rates are really high and colorectal cancer.

Melanie:  Then, the disparities, why, in your opinion and your research, based on your research, why do you think this is happening? Do they have limited access to medical care? Are there not areas around them or within driving distance? Explain some of these disparities.

Dr. Yao:  Sure, I think it's multi-faceted. First off, a lot of incidence disparity is actually due to lifestyle factors. I think the high obesity rates in rural Appalachia and high smoking rates, not much exercise, these kind of things going on. There might be also some environmental risk factors, too, because coal mining has been going on for many-many decades. Some of the water and soil are polluted.  So, that's for the incidence part. When we talk about health care access that treatment, then, of course, they are really far away from lot of comprehensive cancer centers. So, they don't get as much screening as other people do, and when they get cancer they don't get same quality of cancer treatments or new treatments.

Melanie:  Do you think they have an inadequate awareness of the screening or just not the ability to get to a screening?

Dr. Yao:  I think it depends on which cancer we are talking about. I think for breast cancer a lot of patients out of that group have done a lot of great work. So, I think people are pretty aware of breast cancer risks and benefits of screening. But, for colorectal cancer screening or lung cancer screening, that's more complicated than breast cancer screening. So, for like lung cancer screening it just gets going so we probably need to do more health education to raise awareness in people of lung cancer screening. But, I want to say that also the access issues in the mountains and in the rural Appalachia is that there's just not many screening facilities there. At UVA, we actually have a bus, so they actually drive into rural Appalachia to help people get a screening, but lung cancer screening, it’s more complicated than just a mammography. When I look at the data of Virginia, I actually found out that the region with the highest smoking rates and, at the same time they don't have any lung cancer screening facilities. They don't have any--literally.

Melanie:  That is really amazing information. What about preventative services and education? Do you see a disparity there in maybe what the schools are teaching about the dangers of smoking or about any of these awareness initiatives that are going on?

Dr. Yao:  Yes, that gets to a different area, it's very much about public health, and how we can work together with local government to do the tobacco controls. It's a lots of historical reasons, I guess, in the rural Appalachia they used to grow their tobacco. Tobacco and coal mining were their major industry for many decades. Now, the tobacco control was pretty successful in other places of the country but not really in the historical region where they grow their own tobacco. There are also not many smoking cessation programs in that area. The best they can get is just a 800-number. You can call, a quit line, but there's no sophisticated intervention programs to help people to quit. At UVA, we have a team and are trying to do a pilot project in Southwest Virginia to help people quit smoking. For the school education, I don't know because I haven't done much research about that. I don't know if they haven't done enough at elementary or middle school. I just don't have the information.

Melanie:  Do you think that there is... and, again, in your opinion an interesting effect of education versus income in these awareness of the dangers of these various things and cancer awareness and screenings, and then, after that what do you think can be done? What would you like to see done about these health disparities in the area?

Dr. Yao:  That's a very good question. I've been asked this question very often. I think the economy should be the first thing we need to address there. A lot of the health disparities you see or social disparities you find there, I think,  are rooted in their economy. Like I just talked, they were very dependent on coal mining and tobacco growing, and this kind of economic pattern is just not sustainable in the globalized world. We're moving from coal as an energy source and also we're doing a lot of tobacco control in the world. So, for that area, we really need to improve their economy. When you think about the social issues or health care issues, you think about their poverty and the employment rates. You will find 'why' because it's just a lot of people don't find a job, and the economy is really bad, and you cannot support a lot of social functions or health care resources. I think the policymakers, the local government should do something to improve their local economy. I think, in the globalized world, we should look for maybe some international investment too, not just from local manufacturing jobs but maybe there are some foreign companies that are willing to do some factory manufacturing jobs in rural Appalachia if they are aiming for US as a market. It's a huge market. I think in a globalized world we should take advantage of a lot of opportunities coming from other countries. I would like to add that in order to solve all these problems, the health care disparities or social issues, I think the local residents or other US citizens who care about the rural Appalachia and low income people in the mountains should take their phone and try to call their elected officials to do something to improve the economy so we can improve other things. That's I think is my best suggestion.

Melanie:  It's a great call to action. Thank you so much, Dr. Yao, for being with us today. You're listening to UVA Health Systems Radio. For more information you can go to www.uvahealth.com. That's www.uvahealth.com. This is Melanie Cole. Thanks so much for listening.