Cancer Mortality:

Rural vs. Urban Areas of Wisconsin

Emily Anshus, Andrea Davis, Callie Fohrman, Anastasia Melnichenko, and Natalie Notham

Micro Economics 57

May 2015

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Understanding the Problem

Nearly everyone encounters cancer in their lives, whether it be directly or through a loved

one. Nationally, cancer is the second most common cause of death and has taken more lives than

cardio obstructive pulmonary disease (COPD), accidents, and cardiovascular disease combined

(Centers for Disease Control and Prevention, 2015). Like many other diseases, cancer can be

prevented by regular check-ups from the doctor. Many cancers have become treatable with the

correct knowledge, techniques, and equipment. Cancer is becoming less of a mystery as

curiosity leads to more knowledge of cancer, and technology is becoming more advanced that

makes treatment possible. Despite these advances, cancer still takes numerous innocent lives.

Upon observation of some data from Wisconsin, there seems to be a correlation between deaths

from cancer and proximity to treatment locations. In rural areas, the mortality rate seems to be

higher than that of more populated urban areas. This study intends to understand this correlation

and begins to comprehend the current effort to defend against cancer.

Benchmarking

The relationship between proximity to a health care facility and patients receiving

medical attention is quite prevalent. Ganz (2002) noted this in her research of cancer patients

seeking care. She remarks, “A regular source of care and access to a health care system with

expertise in cancer treatment will provide the best opportunity for maximizing patient

outcomes…” (Ganz, 2002). This observation indicates that in order to effectively treat cancer,

the patient needs to have full access to the facilities and equipment for the best possible outcome.

In studying breast cancer surgery, Ganz (2002) makes the important observation that “limited

access to cancer specialists and important treatment modalities, such as radiation therapy

treatment…is the reason why…surgery is more limited in rural areas.” This lack of access can

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negatively affect survival rates, leading to a higher rate of death due to cancer. Access to

modern healthcare facilities is crucial for cancer patients’ survival.

In order to receive care for cancer, travelling long distances may be required.

Unfortunately, not all patients are able to travel long or even short distances due to age, current

health conditions, or limited transportation. For this reason, proximity and ease of access to

treatment is often desired for patients in rural areas (Celaya et. al., 2005). The facility within the

community most likely does not provide the most effective treatment for the cancer that is

diagnosed (Ganz, 2002). This would lead to more deaths of preventable diseases, a tragedy.

Hospitals and cancer centers are key factors in treating cancers because they offer “highly

aggressive and experimental therapies…Access to care…can strongly influence the range of

outcomes available to patients” (Ganz, 2002). Hospitals and modern technology are important in

treating cancer and protecting the lives of innocent cancer victims.

Analysis

From the inspiration of other scholars, data was collected to observe the prevalence of

cancer in rural areas. The first set of data collected was the populations of the 72 counties of

Wisconsin in 2010. Appendix A gives a quick glimpse at the distribution of population

throughout Wisconsin, where Milwaukee clearly has the greatest number of people.

Menominee, on the other hand, has the least number of citizens, only 4,317. Southeastern

Wisconsin is considered the urban area of the state; the greater population in this area supports

this fact. The rest of the state is more rural with populations concentrated in smaller towns and

villages.

The distribution of people across Wisconsin led to the research of the number of deaths

due to cancer in each county. The rate of deaths by cancer were used rather than the total

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number of deaths. Rates can be compared whereas numbers cannot because even though one

county may have a lower number of deaths, their population may be small as well which would

Figure 1 The bar graph shows the distribution of deaths by cancer in the counties of

Wisconsin from 2003-2007. Data was found from: http://action.acscan.org/site/DocServer/WI_FactsFigures_2010_120710_L9.pdf?docID=19025

lead to a greater rate. The rate allows comparisons to be made between the counties of

Wisconsin. Figure 1 above graphically shows the rates of death by cancer of each county in

Wisconsin. Interestingly, the rate of death by cancer seems to be relatively consistent across the

counties of Wisconsin. Menominee, however, noticeably has a greater rate of death than any

other county.

The counties significantly above and below the average rate of death by cancer were the

most useful for the study. The twelve counties significantly above average, as determined by the

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Figure 2 This bar graph represents the twelve counties that have a mortality rate significantly higher

than the state average, which is highlighted in red, from the year 2003 to 2007. The data was found from: http://action.acscan.org/site/DocServer/WI_FactsFigures_2010_120710_L9.pdf?docID=19025

American Cancer Society (2011), were selected from the data list and Figure 2, displayed above.

This figure highlights the specific counties that are most useful in describing the relationship

between cancer mortality and proximity to healthcare facilities. Not only is the rate information

important, but the population of these counties gives insight into the rate of death by cancer. As

Population of Counties with Death Rate Noticeably Above Average

County Population County Population

Adams 20,480 Langlade 19,575 Crawford 16,397 Marquette 15,176

Dodge 88,344 Menominee 4,317 Douglas 43,887 Milwaukee 956,023 Juneau 26,547 Oneida 35,689

Kenosha 167,757 Rock 160,739 Table 1 The populations of the twelve counties with rates of death

by cancer above average. Data was found from: http://www.wisconsin-demographics.com/counties_by_population

shown in Table 1 above, only a third of the counties have a population greater than the average

of Wisconsin, about 80,000 people. Interestingly, Milwaukee County has the greatest population

in the state, recording 956,023 people, and is recorded as being above average in the rate of

deaths due to cancer. Other than Milwaukee, there seems to be a trend in counties with fewer

people having an above average rate. Counties that have a smaller population produce a high

rate of death by cancer, and interesting phenomenon.

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Just as the counties significantly above average were isolated, the eleven counties with a

rate of death by cancer that were considerably lower than average were selected and

Figure 3 The bar graph displays the eleven counties that were below the average mortality rate from 2003 to 2007. The average mortality rate is highlighted in red. The data was found from: http://action.acscan.org/site/DocServer/WI_FactsFigures_2010_120710_L9.pdf?docID=19025

manipulated. Figure 3 above highlights these eleven along with the average. Each of the

counties’ rates of death by cancer are given by the graph. Figure 4, illustrated below should be

Figure 4 A graph of the populations of the counties with rates of death by cancer considerably lower

than average. The data was found at: http://www.wisconsin-demographics.com/counties_by_population

considered in juxtaposition with Figure 4. While Figure 4 gives the rates, Figure 5 shows the

populations of the counties. Interpretation of the two graphs suggest that a greater population

may lead to better chances of surviving cancer.

A population-rate correlation is noticeable, but what about healthcare facilities? Rather

than researching the locations of all the healthcare facilities, the locations and quantity of

hospitals, a key player in detection and treatment of cancer, within the counties was more useful.

Research into the number of hospitals in the counties with rates of death by cancer that were

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Number of Hospitals in Counties with Rates of Death Above and Below Average

County Number of Hospitals

County Number of Hospitals

Adams 1 Brown 5 Crawford 0 Clark 1

Dodge 4 Dane 5 Douglas 1 Door 1 Juneau 1 Dunn 1

Kenosha 2 Eau Claire 2 Langlade 1 Manitowoc 2 Marquette 0 Marathon 1

Menominee 0 Taylor 1 Milwaukee 18 Waukesha 5

Oneida 2 Wood 2 Rock 3

Table 2 The number of healthcare facilities in the counties with rates of death by cancer that deviated the most from average.

Source: https://www.wisconline.com/counties/WI_hospitals.html#oneida

either significantly high or low was recorded and are displayed in Table 2 above. The counties

significantly above average are in the first column of the graph and the counties noticeably

below average are in the third column. Twenty five percent of the counties above average have

no hospital within the county lines while each of the counties below average have at least one.

Adequately staffed healthcare facilities with up-to-date equipment seems to correlate with a

lower rate of death due to cancer.

Relevance

It almost goes without saying, the closer a cancer patient is to a state-of-the-art treatment

center, the more likely they are to survive. Reading the figures simultaneously expresses this

correlation. Of the twelve counties that had the greatest rate of death by cancer above average,

Menominee’s rate was the farthest from average. Note also, the county has the least number of

people and no hospital. The high rate reveals a greater number of the county’s population is

dying due to cancer, no doubt a result of the lack of access to a hospital. Although this data

seems shocking, it is important to note that the county of Menominee is an Indian Reservation.

The smaller population is appropriate, and so is the absence of a modern hospital.

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Unlike Menominee, Milwaukee has the largest population in Wisconsin. Even though

Milwaukee has a greater number of healthcare facilities that provide superior equipment and a

larger personnel than that of Menominee, it still has an above average rate of death from cancer.

Because of the large population, the healthcare facilities have to attend to many patients a day;

often times, more patients than a physician can amply attend to. The situation is not going away

either. It is estimated that 900 more doctors are needed every year, but only 150 are coming

from Wisconsin (Wisconsin Hospital Association, 2011). This shortage requires more patients

per doctor, which negatively affects quality of care provided. In addition to a lack of providers,

local hospitals that tend to the poorer communities have been closing rapidly throughout the

Milwaukee County (Thomas, 2014). The result is fewer treatment facilities for the population

that needs it the most. On top of fewer hospitals, the communities face discrimination. “‘Many

rich white people seem remarkably stoic in the face of hospitals closing in African-American

neighborhoods’” (Thomas, 2014). This discrimination likely discourages patients of poorer

communities from seeking treatment from hospitals in neighboring, rich communities. The

greater number of facilities does not necessarily mean more people get the best possible

healthcare, therefore, Milwaukee’s rate of cancer death is above average.

Interestingly, most of the eleven counties with the greatest deviation below average had a

smaller population. Dane county, home of Wisconsin’s capital, was a peculiar find. Considering

the number of people in the county, one would expect a phenomenon similar to that of

Milwaukee. Dane, however, has fewer people and many top-notch facilities. UW-Madison is

likely a great source of improvement for the county. Also, unlike Milwaukee, the population of

Dane is relatively concentrated around Madison and the locations of the medical facilities.

Therefore, medical assistance is readily available to them.

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Marathon, Brown, and Eau Claire have similar situations. Brown County is home to the

Green Bay Packers along with UW-Green Bay, Eau Claire serves as the resting place for the

University of Eau Claire, and Marathon is home to Wausau. These sites are popular locations for

people to either visit, or find a career path. The colleges in Brown and Eau Claire are quite large

and well known for their programs, making them ideal places for young adults to begin their

education. All of these counties have a similarity that leads to the lower rate of death. Their

distribution of population seems to center around specific cities. These urban locations are home

to many of the healthcare facilities, therefore, a majority of the population gets the medical

attention they need. This is a similar situation to the remaining counties with a rate below

average, although, their populations are significantly less. The smaller, centralized locations of

population distribution allow the healthcare facilities to positively impact patients.

To combat against the growing number of cancer incidences and deaths, communities

have begun working together. Local healthcare providers, the Centers for Disease Control and

Prevention, the American Cancer Society, and local volunteers have combined their efforts to

“reduce cancer incidence, morbidity, and mortality through prevention, early detection,

treatment, rehabilitation, and palliation;” efforts known as comprehensive cancer control or CCC

(Behringer, 2010). These coalitions have developed in many communities encouraging patients

to understand their entire situation and options for treatment (Behringer, 2010). Mahon (2002)

believes nurses should bring programs for prevention and early detection to “culture-specific

settings” including, but not limited to, churches, fraternal societies, sisterhoods, and self-help

groups. This would allow for wide-spread knowledge about cancer and could lead to fewer

deaths due to cancer a year.

Large contributors in gearing Wisconsin towards a healthier future are the Wisconsin

State Statutes. In 1993, the Community Health Improvement Process was enacted to “implement

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local health plans to address health conditions impacting their residents” (Lawrence, 2015). This

state-wide plan encourages each county to collect and submit the health information of the

civilians within the communities (Lawrence, 2015). This information can be tracked and a

pattern can be developed. By having the data readily available, each county can set a health

standard goal to work towards and the progress can be easily traced. The Department of Health

Services creates a new health goal for the counties of Wisconsin every ten years (Division of

Public Health, 2015). Currently, the counties of Wisconsin are working toward the plan that was

enacted in 2010, “Healthiest Wisconsin 2020: Living healthier, longer” (Division of Public

Health, 2015). A longer life with less health implications is the ideal result of this plan. Cancer

mortality can be observed with this plan and action can be taken to lower the rates of death in

counties that have higher than average rates.

Interpretation of the Relevance

Preventative measures must be taken in order to lower the rate of cancer mortality

throughout Wisconsin. By focusing on prevention, individuals will be in good health which is

directly related to the health of the community (Behringer, 2010). Healthy, alert individuals are

key factors in having a well-organized community and well run micro economy. Unfortunately,

cancer mortality obstructs this outcome. Although not completely preventable, many types of

cancers can be prevented and cured with early detection, a feat that is accomplished through

healthcare providers. The scarcity of adequate facilities in rural areas of Wisconsin reflects

higher rates of mortality due to cancer. Comprehensive cancer control planning can be effective

in fighting against these high rates. A community that is more informed about cancer can lead to

both early detection, and proper care for those who develop cancer, leading to lower risk of

death. The government has taken an active role in encouraging communities to be healthier by

forming health plans every ten years. Recently, preventative care has been the driving force in

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healthcare. With additional people obtaining healthcare, regular check-ups are becoming more

commonplace. Preventative care allows for health concerns to be addressed early, preventing

many curable diseases from taking young lives. Although communities and the government

have been working diligently to combat cancer mortality, nothing is more helpful than building a

new facility for patients to attend. Building a new hospital, however, is a multimillion dollar

investment that many feel is not worth the time, money, or man power. In order to get proper

care to rural areas, a mobile healthcare clinic may prove effective. Similar to a mammogram

bus, these vehicles could be equipped with the appropriate machines to detect the early signs of

cancer. Early detection is essential with cancer; sometimes, it is the difference between life and

death.

Death by cancer would still occur even if communities, the government, new hospitals,

and cancer detection vehicles were all working to combat against it. Curing cancer cannot be

solved by just one organization or group of people. Precautionary measures need to be taken by

the public, scientists need to develop new and improved prescriptions and methods of treating

cancer, and organizations and the government need to contribute the funds to developers for their

projects. This form of cooperation often does not come easily. Funds are withheld, trials on new

methods are halted, and people ignore the effects of bad health habits. What many people

regrettably ignore is the fate that one in three Americans are likely going to develop a form of

cancer (Charette, 1994). Action is often taken retrospectively; even though the effects of cancer

may not be necessary in the present, the future may hold a different fate. Action needs to be

taken now to save the lives of those with preventable diseases. New hospitals should be built

and CCC coalitions should be better funded to aid those in need because even though you may

not be affected right now, the future is unknown territory.

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Resources

Behringer, B., Knight, M., & Lofton, S. (2010). “Models for local implementation of comprehensive cancer control: meeting local cancer control needs through community collaboration.” Cancer Causes & Control, vol. 21, no. 12: 1995-2004. Celaya, M., Gibson, J., Greenberg, E., Rees, J., & Riddle, B. (2005). “Travel distance and season of diagnosis affect treatment choices for women with early-stage breast cancer in predominantly rural population (United States).” Cancer Causes & Control, vol. 17, no. 6: 851-856. Centers for Disease Control and Prevention. (2015). Faststats: Leading causes of death. (Web). Retrieved from: http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm Charette, J. & Gale, D. (1994). Ocnology nursing care plans. El Paso, Texas: Skidmore-Roth Publishing, Inc. Division of Public Health. (2015). Wisconsin state health plan – Healthiest Wisconsin 2020. (Web). https://www.dhs.wisconsin.gov/hw2020/index.htm Ganz, P. (2002). “What outcomes matter to patients: A physician-researcher point of view.” Medical Care, vol. 40, no. 6: III11-III19. Mahon, S. (2002). Eds. Jennings-Dozier, K. & Mahon, S. Cancer prevention, detection, and control: A nursing perspective. Pittsburg, Pennsylvania: ONS Publishing Division. Lawrence, J. (2015). Community health improvement assessment and plans. (Web). Retrieved from: https://www.dhs.wisconsin.gov/chip/index.htm Thomas, Lillian. (2014). Poor Health. Post Gazette. Retrieved from: http://newsinteractive.post- gazette.com/longform/stories/poorhealth/1/ Wisconsin Hospital Association. (2011). “Physician shortage threatens patient access, quality.” The Valued Voice, vol. 55, no. 46.