Portsmouth cancer death rates highest in state. Why?

In the first part of her three-part series for The Virginian-Pilot, 2012 National Health Journalism Fellow Amy Jeter reports on why people in Portsmouth are more likely to die of cancer than those living elsewhere in Virginia. Other stories in this series include:

By Amy Jeter
The Virginian-Pilot

Part 1 of 3

“What he tells me, I can handle it,” Pamela McLurkin says.

The doctor is running behind on this, of all days, and Pam is stranded in exam room 24 of Virginia Oncology Associates’ Norfolk office.

Her blood has already been drawn, temperature and blood pressure taken, and pill bottles excavated from her handbag to match with the list in her electronic medical file.

She has greeted Hannah the therapy dog, called Medicaid transport to arrange a ride back to Portsmouth, and then given up on being ready at the time she requested.

Settled in a chair next to a computer and a sink, Pam chats about her grandchildren and which TV reruns she watches when she can’t sleep: “Leverage,” “Criminal Minds,” “Three’s Company.”

Then, her mind lurches to the present.

“It can’t be so bad,” Pam says. “It’s over, the worst, already.”


Database | See cancer incidence, mortality rates throughout Virginia


She’s dressed impeccably, maybe a little more subdued than usual: brown button-up shirt and slacks, dangling heart earrings, false eyelashes, manicured fingernails. Everyone says she doesn’t look like she has cancer, and she knows it. She’s proud of it.

At 6 feet and 250 pounds, Pam hasn’t dropped an ounce since she started taking hormone pills four months ago. She wore wigs even before the medicine made her hair fall out – usually short and dark, with a blond or magenta streak in front.

The worst thing about the medication is the monster hot flashes, but Pam accepts them. They mean her tumors are shrinking, and she has watched her right breast grow softer, less red, less painful.

But what you see with your own eyes and feel with your own hands isn’t always what the hospital scans show.

Today, Sept. 14, her oncologist will pronounce the verdict on her breast cancer. He already said there is no hope that it will be gone from her body; stage 4 cancer is not curable.

But it can be treatable. If the hormone pill is working, Pam will have more months – maybe even years – like this past summer. A life pretty close to normal.

If not, her doctor will switch to another weapon in his arsenal – chemotherapy – and she’ll probably start feeling really sick. She’ll probably start looking like she has cancer.

“Come on, man,” Pam says, still waiting. “Tell me something.”

People in Portsmouth die of cancer at the highest rate in Virginia.

That doesn’t mean Portsmouth residents are diagnosed more frequently with the disease – the city’s incidence rate ranks ninth. It means people in Portsmouth are more likely to die from cancer.

Between 2006 and 2010, Portsmouth’s cancer mortality rate was 226.5 per 100,000 people, according to the Virginia Department of Health. The state’s rate was 177.4; the national rate was 175.3.

Other South Hampton Roads cities also had high rates. Western Tidewater – including Franklin, Suffolk and Southampton and Isle of Wight counties – ranked third in the state; Norfolk was sixth, Chesapeake 13th. Virginia Beach had cancer mortality rates among the state’s lowest, behind only Northern Virginia.

People in Portsmouth are more likely to die of cancer than those living in Virginia’s rural southwest, where thousands flock to an annual free clinic held at the Wise County Fairgrounds.

More likely than residents of the Petersburg area, which has the highest rate of diagnosed diabetes in the state and the lowest percentage of adults reporting exercise or physical activity.

More likely than folks on the Eastern Shore, where some patients drive miles and pay to cross the Chesapeake Bay Bridge-Tunnel for cancer treatment in South Hampton Roads.

The question is: Why?

It’s not because Portsmouth’s population is older – the numbers were adjusted to account for age. And it’s not because it’s always been that way: The city’s death rates for most cancers have dropped along with Virginia’s since the mid-1990s, but other areas of the state have improved more.

High mortality rates generally are related to a truism of cancer: It’s more likely to be stopped – or at least held in remission – if detected and treated early.

In Portsmouth, 43 percent of cancer diagnosed between 2005 and 2009 was found in early stages, before the disease had spread. That percentage was among the worst in the state, but not far off Virginia’s average of 46 percent.

A number of factors that stand in the way of early cancer detection combine to push death rates higher in several local districts, but Portsmouth has something of a perfect storm, according to doctors, researchers, advocates and public health leaders:

-- Blacks have the highest mortality rates for most cancers in the United States. They often have more aggressive cancers, and a culture of fear leads some black patients to avoid screenings and ignore symptoms; 53 percent of Portsmouth’s 95,700 residents are black.

-- People with low incomes are more likely to have unhealthy habits and have a harder time getting preventive care and treatment; 15 percent of Portsmouth’s residents are considered poor by federal standards.

-- Poorer people are less likely to schedule regular medical checkups, either because they have no insurance or because they can’t afford the out-of-pocket costs. When they go to the doctor, they seek treatment for existing problems rather than preventive care; 15 percent of Portsmouth residents have no health insurance.

-- People with less education tend to be less vigilant about preventive health care, including cancer screenings; 16 percent of Portsmouth residents who are 25 or older lack a high school diploma or equivalent.

-- Primary care doctors help patients get cancer screenings as needed, but some Portsmouth neighborhoods don’t have a sufficient number of primary care physicians, according to the federal government.

“We can talk about screening until we’re blue in the face,” said Dr. Lloyd Shabazz, an oncologist who has practiced in Portsmouth for 14 years and heads Delta Oncology Associates. “If people don’t pick up on it and follow through and do the things that they know should be done, then you’re going to keep getting the same results.”  

Pam is the baby sister of six children, the one who has never met a stranger, the one who likes to see and be seen.

She is 55 and has worked most of the past four decades – usually helping special-needs children but also doing odd jobs, such as ringing the Christmas bell for the Salvation Army.

Pam is always on the phone: hers or her sister Joyce’s or someone else’s. She calls Joyce and her best friend Rosa every day unless she’s visiting them in person.

“Girl,” she’ll say. Then she’s off on another story about this friend, that relative or her own self, drawing chuckles or shrieks of laughter.

“I don’t let too many things bother me,” Pam says, and her friends and family back her up on that.

“She’s always taking on things like it wasn’t no big deal,” says her sister Joyce Barnes, who is 69.

Pam isn’t sentimental about growing up in Portsmouth in the 1960s and ’70s. She remembers playing near fields of coal by her home in Washington Park, a public housing project later found to be contaminated with lead from a foundry.

Her father worked at a soybean processing plant near the Jordan Bridge. Her mother died during a hernia operation when Pam was 12. Five years later, her father passed away – from cancer.

Joyce and an aunt looked out for Pam.

“When I left home, everywhere I would move, she would come,” Joyce said. “It was just like she was growing up with my kids.”

As a teenager, Pam rooted for Wilson High at football and basketball games before dropping out. A few years later, she met her husband. They had three children, and her house was known as a gathering place for Park View kids. She somehow found time to earn a GED.

But the marriage eventually crumbled, and Pam moved to Atlanta to be near her daughter. Then her Hampton Roads relatives began dying off.

Joyce’s grandson was the first, shot in 2009. Next, Joyce’s son died from lung cancer, then her daughter from heart disease.

By March 2011, Pam’s aunt, a brother-in-law and another nephew all had passed away as well, the last found dead of a heart attack in his newspaper delivery truck.

Her brother was battling lung cancer. Her eldest sister, Hattie, was bedridden, and Joyce, plagued by arthritis, wasn’t doing much better.

With all of that going on, Pam moved home.

Seventeen oncologists list a practice in Portsmouth, according to the Virginia Board of Medicine.

Subtract one with an expired license, 11 who work exclusively for the Naval Medical Center and one who says she spends no time at her Portsmouth location. That leaves four.

Other than the naval hospital, only one facility in the city provides mammograms, and Portsmouth will eventually lose its only cancer radiation therapy program.

Bon Secours Maryview Medical Center plans to move the equipment seven miles to Suffolk, where the health system is building a comprehensive cancer center.

About 3 percent of the 7,000 patients diagnosed and treated in Sentara Healthcare’s Hampton Roads cancer network each year come from Portsmouth, where the health system’s presence is limited to a nursing home, an outpatient therapy center, a surgical rotation site and a mobile service providing medical care and other support for the elderly.

But a lack of providers in Portsmouth doesn’t necessarily mean the city’s residents are far from care. Depending on their neighborhood and mode of transportation, some live only minutes away from facilities in Chesapeake, Norfolk or Suffolk.

Leeanne Sciolto, Bon Secours’ administrative director of oncology services, says distance alone doesn’t predict whether patients can get to treatment.

“Access is going to mean different things to different people,” she said. “It could mean ‘I’m close enough to walk.’ It could mean ‘My friend can drive me.’ ”

Dr. Elizabeth Lamont’s research supports that idea. Her study found that impoverished urban areas have the same amount of cancer screening, treatment and post-treatment care as other neighborhoods. She concluded that poorer people might be diagnosed with cancer at later stages and even survive a shorter amount of time, despite having adequate care nearby.

“The idea is you could have maybe a hospital in your backyard, but you don’t have insurance,” said Lamont, an associate professor of medicine and health care policy at Harvard Medical School and Massachusetts General Hospital Cancer Center. “So, what good is that?”

The number of primary care physicians seems to matter, research has shown. An increase in primary care doctors has been linked to earlier detection of breast cancer and decreases in incidence, late-stage diagnosis and even death rates for colorectal cancer.

That connection makes sense to Dr. Ranjit Goudar of Virginia Oncology Associates. Primary care doctors manage patients’ cancer screenings along with their general health, and they also care for survivors, who are susceptible to a recurrence.

“Our specialty, maybe more than any specialty, really is completely dependent on sharp primary care doctors,” Goudar said.

That’s a problem in Portsmouth’s greater downtown area, where there is a shortage of primary care doctors.

The Hampton Roads Community Health Center opened its doors in 1995 to fill the void, charging fees on a sliding scale based on financial need.

The center got help in late 2005, when Bon Secours opened a free clinic next door to Maryview for low-income, uninsured patients. Six years later, the Bon Secours Care-A-Van started making regular stops in Portsmouth, and the health system recently set up a new two-physician primary care practice near the hospital.

Still, uninsured patients in Portsmouth had limited primary care options for a while, said Dr. Subir Vij, the community health center’s medical director.

Until a few years ago, he said, “we were the only gig in town.”

After moving back to Portsmouth, Pam started working for a personal care agency and a janitorial service. Neither provided health insurance, so she visited the Care-A-Van for primary care – usually to get refills for medicine treating her diabetes, high cholesterol and high blood pressure.

That’s why she showed up in March, when the van was parked at Calvary Evangelical Baptist Church in Portsmouth.

She also asked the nurse practitioner to look at her right breast.

Pam’s breasts had been lumpy since she was a girl. When she was a teenager, her doctor punctured the hard nodules with a needle. No fluid came out, so he told her they were benign cysts, caused by chocolate, foods containing yeast and birth control pills.

The cysts tended to grow, and Pam kept tabs on them. She’d go to the doctor, and a surgeon would cut out a lump. She’d find another, and the cycle would repeat. Over the years, half a dozen surgeries left her breasts pockmarked like the surface of the moon.

She was in no hurry to go under the knife again, especially without health insurance. She couldn’t afford to miss work. So when Pam felt a hard, quarter-sized knot under her right arm, she let it go for nearly a year.

Then something happened in February. Her breast hardened and swelled up so much she had to get a bigger bra, replacing size 44D with 46DD. It grew warm, hurt like a toothache and turned the warm rose-red of a sunrise.

The throbbing kept her up at night, calmed only by four or five Aleves taken all at once.

Her job cleaning bathrooms, break rooms and cafeterias became impossible. Instead, the janitorial service let her dust with her left arm. The personal care agency assigned her to clients who only needed someone to sit with them while they slept.

Pam showed her swollen breast to her sister, who told her to go to the doctor.

On the Care-A-Van, nurse practitioner Jimmy Cooper felt several lumps, one the size of a golf ball. He worried that scarring from her surgeries might be obscuring other serious symptoms.

To treat the swelling and soreness, he prescribed an antibiotic. He also scheduled a mammogram and asked Pam to return in two weeks.

Three weeks later, she met the truck at Grove Baptist Church in Portsmouth. She’d missed the mammogram but was feeling better. Her breast had softened. She demonstrated by pressing down on it with her fingertips, careful of her manicured nails.

Her face didn’t tense up when Cooper tested for tenderness, but he still detected hard spots.

“I’m glad that something brought you back,” he said, and called to schedule another mammogram. “You need to get this checked out.”

That’s when it dawned on Pam:

This could be cancer.

Tomorrow: The diagnosis

This series was first published in The Virginian-Pilot on December 9, 2012

Picture Credit: Vicki Cronis-Nohe | The Virgnian-Pilot