Elizabeth is a student working towards a Ph.D. in Epidemiology, with a research focus on lung cancer.
Alabama's Cancer Plan
The Alabama State Cancer Plan, for the past few decades, has focused solely on smoking cessation, anti-smoking campaigns, and screening services for "high-risk" individuals. However, other studies and research suggest that this process grossly ignores several other important risk factors for developing lung cancer.
This article examines the statistics and demographics of several of these risk factors—COPD diagnosis, socioeconomic status, low levels of CoQ10, CAD diagnosis, ethnicity, and access to early or preventative screening - and how the numbers can and should be applied to lower Alabama, where the lung cancer burden is quite high.
Lung cancer—specifically non-small-cell carcinoma—is the most common cancer worldwide, the third most common cancer in the United States (U.S. Cancer Statistics Working Group, 2021), and the third most common cancer in Alabama (American Cancer Society, 2018).
The age-adjusted incidence rate, as of 2018, for lung cancer in Alabama was 61.1 per 100,000 persons, with a 95% CI. Between the years of 2009-2018, the age-adjusted average incidence rate of lung cancer in Baldwin County, for all genders, was 67.7 per 100,000 persons, again with a 95% CI; it was 69.5 per 100,000 persons in Mobile County. Mobile and Baldwin counties make up the lowest part of Alabama—the Gulf Coast
Between the two, there were 500,559 individuals over the age of 18 (United States Census Bureau, 2020). For any lung cancer research into this at-risk part of the country, this is the base population—which can of course be split into smaller population groups based on ethnicity, gender, income level and so forth.
Currently, there are a number of recognized risk factors for developing lung cancer; the most well-known is, perhaps, smoking cigarettes or other tobacco product use. Other risk factors include asbestos exposure, a COPD diagnosis, poverty, particulate air matter, lowered CoQ10 blood serum levels, and more.
Air pollution and asbestos exposure, like cigarette smoking, have been explored in-depth as causes for lung cancer, and the results of the studies are widely publicized and well-known to the public.
However, lung cancer affects a disproportionate number of black men over other racial and gender groups, and in a county where the incidence rate is significantly higher than the national average—54 per 100,000 persons (American Lung Association, 2022)—public health officials can no longer afford to semi-ignore other risk factors and causes.
Exploring risk factor prevalence, it should be noted that 22.7% of people aged 18 and over reported smoking cigarettes in the southern region of the United States, according to data from the 2016 National Survey on Drug Use and Health (Centers for Disease Control and Prevention, 2021).
This survey relied on participants self-reporting, which leaves room for bias in that typically people will underreport a risk behavior. Newer data suggests that the smoking rate for Alabama is 20% (American Lung Association, 2022), which is still significantly higher than the national average.
The same source reports that only 5% of those deemed “high risk” underwent preventative screening for lung cancer, lower than the national average of 6%. Black Americans in Alabama receive an early diagnosis significantly less often than their white counterparts, receive treatment significantly less often, and more often experience a lack of treatment.
Furthermore, while not the poorest counties in the state, the poverty rates for Baldwin and Mobile counties are 11.8% and 19.3%, respectively. COPD affects between 8 and 11% of adults in Alabama, and a great many in the state are at risk for low serum levels of CoQ10, as explored further below.
The most recent state cancer plan focuses heavily on smoking, second-hand smoke exposure, and radon exposure and knowledge as the primary prevention measures for lung cancer in the state.
The actions outlined include, but are not limited to, offering reduced cost cessation programs, lobbying to increase the price of cigarettes, and conducting awareness campaigns and mass media education campaigns. While the available data suggests that the incidence of lung cancer in Alabama may be decreasing slightly, some sources note a higher incidence than others, and the differences are notably small.
The rate of lung cancer deaths may be more telling—it has remained relatively stable between 2014 and the estimates for 2022. This suggests that widely accepted smoking education and cessation programs may not be as effective in helping to prevent lung cancer as public health officials would like.
Currently, preventative screening is recommended for high-risk individuals— defined as those who are between the ages of 50 and 80 years old, who have a smoking history of 20 or more pack years (2 packs a day for 10 years, one pack a day for 20 years, etc.), and who currently smoke or have quit within the last 15 years (American Lung Association, 2022).
This grossly ignores the other risk factors for developing lung cancer, and as previously mentioned, only 5% of those deemed high-risk are being screened (American Lung Association, 2022). According to a study published in PLoS One, COPD diagnosis—even a self-reported diagnosis—is associated with a significant increase in lung cancer mortality.
This study included 26,927 participants from the Southern Community Cohort Study in a nested case-control study—using available Centers for Medicare and Medicaid algorithms and data to validate diagnoses and estimate potential misreporting. The study concluded that the lung cancer mortality rate was 2.3 times higher among those with a COPD diagnosis than those without.
A separate study regarding COPD found an incidence rate of 5.664 per 100,000 working adults in the United States, with a 95% confidence interval (5.434-5.881 per 100,000 persons), including a rate of 6.679 per 100,000 working adults who have never smoked (Doney et al., 2014).
Applying these conclusions to the population of southern Alabama, this leaves 326,694 working adults who may be at an increased risk for COPD but who have never smoked, and are therefore at an increased risk for lung cancer but are not targeted by the state cancer prevention plan.
This represents a fairly significant portion of the population that is at an increased risk for lung cancer development and mortality, and yet preventative efforts are not currently directed towards them.
A study published in Family Medicine & Community Health concluded that poverty contributes significantly to the risk of developing lung cancer. This retrospective cohort study examined death rates and causes from the CDC—along with 95% confidence intervals—and applied multiple regression analyses to help researchers make conclusions about the connections between lung cancer and smoking, geographical location, and socioeconomic status.
The study found 0.47, 0.293, 0.335, and 0.101 zero-order correlations between lung cancer deaths and annual income below the poverty level for white men, white women, black men, and black women respectively (de Grubb et al., 2017). The 2019 poverty rate for Mobile County was 18.8%, and for Baldwin County it was 10.4%.
Given a positive correlation between living at or below the established poverty line, this again represents a significant portion of the population that is at risk for lung cancer, regardless of smoking status—though other studies show that lower-income individuals are more likely to display this particular risk behavior.
Regarding preventative screening, the southeastern region of the United States has the lowest density of Lung Cancer Screening Registry (LCSR) facilities, though it also has the largest lung cancer and smoking burdens (Minal et al., 2019). Studies have shown that LCSR facility variability is tied to increased lung cancer burden and poorer lung cancer outcomes.
There are 83 LCSR facilities in Alabama as of 2022, with only 15 of those in the southernmost part of the state. 18% of the state’s LCSR facilities are located in an area that contains only 12.5% of the state’s adult population, yet only 5% of those defined high-risk are screened, and the defined high-risk category is not nearly high enough.
Mobile and Baldwin Counties have the resources to expand preventative screening in terms of age group, risk behavior, and income level, not merely smoking status.
As previously mentioned, low blood serum levels of coenzyme Q10 (CoQ10) have been shown to increase risk of developing lung cancer. In one nested case-control study, 201 lung cancer cases and 395 matched controls—taken from the Southern Community Cohort Study—were tested for plasma CoQ10 levels (Shidal et al., 2021).
Researchers used conditional logistic regression models to estimate odds ratios and 95% confidence intervals. This study determined an odds ratio of 0.57, and concluded an inverse relationship between plasma CoQ10 levels and lung cancer risk, which was shown to be even more significant among current smokers.
Several health factors are linked to lower levels of CoQ10, including heart disease, diabetes, and statin usage (typically for treating high cholesterol). Additionally, CoQ10 levels decrease naturally with age.
As of 2017, heart disease was the leading cause of death in Alabama with a rate of 223.3 per 100,000 adults. The most current data shows that prevalence of coronary artery disease is 7.8% in Baldwin County and 8.8% in Mobile County (Centers for Disease Control and Prevention, 2018).
Diabetes has been diagnosed in an estimated 15.2% of the adult population, with a further estimated 127,000 living with the disease undiagnosed. Furthermore, 37% of the adult population have prediabetes and are at significant risk for developing diabetes in the future. 40.1% and 36.8% of adults screened in Baldwin and Mobile counties, respectively, have high cholesterol (Centers for Disease Control and Prevention, 2018).
These are diseases that often go hand-in-hand, as diabetes and high cholesterol are also risk factors for developing heart disease. Again, a large portion of the adult population that is not being targeted by primary prevention efforts.
Finally, multiple studies have shown that there are racial disparities in lung cancer prevalence nationwide. Across the board, lung cancer rates are higher amongst black male Americans than other groups.
According to one such study, this particular racial disparity is not expected to disappear any time soon based on current trends, despite significant decreases in smoking status between 1999-2012 among both genders and racial groups (blacks and non-Hispanic whites) (Tabatabai et al., 2016).
This study used a population that represented roughly 77% of the United States total population, and was divided into 8 regions. Researchers used a longitudinal linear mixed-effects model and data from the U.S. Cancer Statistics section of the Centers for Disease Control and Prevention in order to make inferences regarding these gender and racial disparities in lung cancer incidence.
Mobile County reported a black population of 36.2% at the most recent census, while Baldwin County reported 8.8%. This suggests that primary prevention efforts and screening should more heavily include the black population in at least Mobile County, and that access to care and equitable distribution of healthcare resources may be a concern with regards to the lung cancer burden in this area.
In all lung cancer studies, development of lung cancer or death from lung cancer serve as the dependent variable. Unfortunately, as discussed, there are a great number of independent variables—age, smoking status, other health conditions or concerns, socioeconomic status, geographical region, race, gender, etc.
Confounding is something all researchers will need to account for when studying lung cancer, as has been accounted for using multiple regression analysis—a tool used to examine the relationship between two variables and estimate the equation that describes this relationship—in at least one of the aforementioned studies.
Further study is always warranted, perhaps even advised, but based on the information available from a wide range of studies, it is safe to say that focusing all primary prevention efforts on smoking cessation and education can no longer be considered effective in lessening the lung cancer burden in southern Alabama—or nationwide.
Ideally, screening education should be provided, in addition to widening the definition of “high-risk” and therefore access to preventative screening. Education efforts should continue to focus on anti-smoking campaigns, but should be expanded to include other risk factors as well as environmental information.
These efforts could be evaluated by again analyzing the lung cancer burden and percentage of the high-risk population receiving screening services five years after implementation. An informed, educated population is, perhaps, a healthier one.
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Shidal, C., Yoon, H., Zheng, W., Wu, J., Franke, A. A., Blot, W. J., Shu, X., & Cai, Q. (2021). Prospective study of plasma levels of coenzyme Q10 and lung cancer risk in a low‐income population in the Southeastern United States. Cancer Medicine, 10(4), 1439–1447. https://doi-org.libraryresources.columbiasouthern.edu/10.1002/cam4.3637
Tabatabai, M. A., Kengwoung-Keumo, J.-J., Oates, G. R., Guemmegne, J. T., Akinlawon, A., Ekadi, G., Fouad, M. N., & Singh, K. P. (2016). Racial and Gender Disparities in Incidence of Lung and Bronchus Cancer in the United States: A Longitudinal Analysis. PLoS ONE, 11(9), 1–19. https://doi-org.libraryresources.columbiasouthern.edu/10.1371/journal.pone.0162949
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US Census Bureau. (2021). U.S. Census Bureau quickfacts: Baldwin County, Alabama. Retrieved April 6, 2022, from https://www.census.gov/quickfacts/fact/table/baldwincountyalabama/PST045221
This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.
© 2022 Elizabeth Watson