Smoking rates in the U.S. have been falling for decades. That has also brought down the number of people who develop lung cancer. Still, lung cancer kills more people in the United States each year than any other type of cancer, and it affects some racial groups more than others. The reason for this disparity goes beyond tobacco, but experts believe that smoking is the best place to begin closing the gap.
Marcia Fountain of Omaha knows she is fortunate to have lived through her battle with lung cancer. Fountain, 67, is African-American, mostly retired from a career working with the developmentally disabled. After smoking for 30 years, she quit in 1991. In December of 2010, doctors discovered that a spot found on her lung was cancer. When she was first diagnosed with lung cancer, she thought back to her grandfather's smoking habit.
"He always used to smoke those short Camels," Fountain said. "And then cough. He used to cough all the time. Finally he went to the doctor, but it was too late."
Fountain's grandfather died when she was just 14. After her diagnosis, she wondered if she would share his fate.
The American Cancer Society estimates that lung cancer will make up about 14 percent of all cancer cases in Nebraska this year, but about 25 percent of cancer deaths - more than breast, colon and pancreatic cancers combined.
According to data from the Nebraska Department of Health and Human Services, lung cancer has a disproportionate impact on African Americans. From 2000 to 2009, black Nebraskans developed lung cancer at a rate 30 percent higher than whites. The death rate from lung cancer among blacks was about 40 percent higher than whites. Analysis from the American Cancer Society also shows Nebraska has a lung cancer death rate for African Americans that is higher than most states.
Lung cancer can be caused by many things other than smoking, like environmental pollution, or radon gas, which naturally occurs in the soil at high levels in eastern Nebraska. Smoking, however, is still the main culprit, according to Dr. Mark Clanton, chief medical officer of the American Cancer Society's High Plains Division.
"When we talk about lung cancer, we have to talk about smoking," Clanton said.
The most recent smoking data seem to show the origins of the disparity between white and black lung cancer rates. From 2009 to 2010, 22 percent of African Americans in Nebraska were smokers compared with just 16 percent of whites. But Clanton said those numbers can be deceiving: national surveys show black smokers tend to start later, and smoke less, than their white counterparts.
"You have people who, when they smoke, they're actually smoking less," he said. "But then we have this strange outcome of them having more cancers and dying from those cancers more frequently."
Researchers are not exactly sure why it's more likely for African Americans to develop cancer even while smoking less, but there are many possibilities. Clanton said disparities can reflect gaps in income and health care access. Also, black smokers are much more likely than whites to use more harmful menthol cigarettes.
According to Dr. Rina Das at the National Cancer Institute's Center to Reduce Cancer Health Disparities, research has uncovered genetic differences, as well. Das said blacks and whites don't process cancer-causing toxins from cigarettes, like cotinine, the same.
"Cotinine stays longer in the bloodstream in African American patients because there are some of these genes that are mutated in African American smokers," Das said. "So you cannot detoxify yourself as well as white patients would do."
Researchers will continue unraveling the many causes of lung cancer disparities, but they agree targeting tobacco use is the best way to close the gap.
Nebraska tries to curb smoking with a 64-cent tax on each pack of cigarettes and an indoor smoking ban. The state runs the Nebraska Tobacco Quitline (1-800-QUIT-NOW) and funds youth anti-smoking groups like No Limits. To get at specific disparities, the state sponsors groups to reach out on a local level.
For Clanton, the best sign that the lung cancer gap between whites and blacks might narrow in years ahead is that smoking rates have been falling faster for African American men 25- to 34-years-old than for white men that age.
"If the rate of smoking continues to drop, in the next 30 to 40 years we may have equal death rate outcomes among African American men and white men when it comes to lung cancer," he said.
Smoking and lung cancer rates for African American women have remained even, by comparison.
Marcia Fountain stopped smoking, cold turkey, 20 years before doctors discovered her lung cancer. They told her she was fortunate that it was found early - stage one. A portion of Fountain's lung was surgically removed, and In February 2012, she was declared cancer-free.
Dr. Karin Trujillo was Fountain's surgeon at the Nebraska Medical Center in Omaha. She said not all patients are as fortunate.
"Seventy-five percent of patients who present have inoperable lung cancer," Trujillo said. "So she's within that lucky subset, that 25 percent who could obtain surgery, and then the luckier still who are stage one."
Fountain said she knows that because she smoked for so long, she'll never be able to let her guard down completely.
"I'm not giving up the fight," she said. "I think I have a lot more living and a lot more things to do, if my health allows me to do it."