The following is a transcript of an episode of From the Front Row: Student Voices in Public Health, the University of Iowa College of Public Health’s student podcast. This episode features a conversation between hosts and CPH students Oge Chigbo and Emma Meador and College of Public Health epidemiology professor Mary Charlton. They discuss cancer in Iowa and Dr. Charlton’s work with the Iowa Cancer Registry.

Oge Chigbo:
Welcome back to From the Front Row, brought to you by the University of Iowa College of Public Health. I’m Oge Chigbo.

Emma Meador:
And I am Emma Meador. If this is your first time with us, welcome. We’re a student run podcast that talks about major issues in public health and how they’re relevant to anyone, both in the field of public health and outside of it.

Oge Chigbo:
Today, we sat down with Dr. Mary Charlton, who is an Associate Professor in the Epidemiology Department here at the College of Public Health. We’ll be discussing the 2020 Cancer in Iowa report and an exciting collaboration that she had with the IDPH on an ovarian cancer study.

Emma Meador:
So let’s go right into this week’s episode.

Oge Chigbo:
Okay. So today we have Dr. Charlton here with us. So Dr. Charlton, hi.

Mary Charlton:
Hi, how are you?

Oge Chigbo:
Good. We also have Emma, which is my co-host here today, with us.

Mary Charlton:
Hi, thank you.

Oge Chigbo:
Going to go straight into the questions for today. So our first question is, what inspired you to step foot into the field of public health, specifically cancer epidemiology?

Mary Charlton:
Okay. Well, as most things I think, that happened in my life, it was fairly accidental. I would like to say it was a very purposeful path, but I went to nursing school here at the University of Iowa. I was the only person in my nursing school class who was not excited at all about going over to the hospital and doing the clinical part. I loved the classes and I especially loved the one research class that we took. And I was the only one who loved that research class that we took.

Mary Charlton:
So I knew back then that I was probably a little bit different from my peers. And then I was really fortunate, because I really didn’t know much about public health and right about that time, I was realizing that probably, nursing was not the thing I was going to be able to do for the next 40 some years. An old friend that I grew up with an Omaha and played soccer with, came to school at the University of Iowa to get a master’s degree in biostatistics. And I didn’t even know what that was, but she contacted me to get together when she moved to Iowa City. And she introduced me to a lot of people who were students in epidemiology and biostatistics. And I thought, “Wow, I’m really interested in this field and this is something I would like to pursue.”

Mary Charlton:
So that’s right when the College of Public Health came out of the College of Medicine and so I was one of the earlier students in what was then, the new College of Public Health. Oh, sorry, and your cancer epidemiology part of your question. I really just enjoyed EPI-1, which at that time was taught by Dr. Lynch, who has since been my mentor for a lot of my career. And he ran the cancer registry and was the PI of the Ag health study and had been the PI of a big radon study.

Mary Charlton:
I just loved his examples as they related to cancer. And it was just something I was always really interested in. After I finished my master’s degree, I went to work in the Department of Family Medicine as a research assistant and learned about, because they were doing a lot of studies about disparities in cancer screening, between urban and rural people and how to improve screenings among rural populations. So I got interested in that aspect. So when I came back to the University of Iowa, I was immediately interested in working with Dr. Lynch and the cancer registry and looking at rural, urban disparities in cancer prevention screening and control.

Emma Meador:
Awesome. Well, thank you for sharing. That’s a great story. And I would just like to say, congratulations on your publishing of the Iowa 2020 Cancer Report. Can you tell us a little bit about the work you accomplished that went into this report?

Mary Charlton:
Sure. Well, it’s really a big team effort to get that report out each year. We look at all the previous number of incidents and mortality numbers, and we put our heads together and think about what current events could be impacting cancer trends. And then we project out what the cancer trends will be or the cancer rates will be for the following year. So we do that, Dr. Lynch and I and Dr. West, over at the registry.

Mary Charlton:
We’ve also put in some new features, like showing the counts of cancer survivors by county, in Iowa. We hope that people, different community organizations and public health organizations will use that information to understand how many people are out, living in the community that have a history of cancer. And we can do that because the cancer registry data goes back to 1973.

Mary Charlton:
So we can’t really account for people coming into the state that weren’t diagnosed here, but it gives us a pretty good idea of how large the cancer survivor population is in Iowa. And then each year we feature a special, either a certain type of cancer, a certain population, a certain exposure. And this year we did ovarian cancer because we have quite a few studies going on in that realm. And that’s another one where it looks like there’s some rural, urban disparities in terms of who makes it to a gynecologic oncologist, which is the type of provider that’s specially trained to treat ovarian cancer and can generally, get the best outcomes. So that’s why we chose ovarian cancer.

Emma Meador:
And then going off of that, during your investigation, did you notice any significant or specific trends regarding disparities or health equity? I know you just touched on that a little bit, but if you could elaborate?

Mary Charlton:
Sure. Yeah. Dr. Lynch had been invited, way back when he was PI of the registry, by the CDC to participate in a study with, it was Iowa, Missouri, and Kansas, where the cancer registries all participated in this ovarian cancer patterns of care study. And it definitely looked like there were some disparities in terms of who’s getting referred to a gynecological oncologist, who is actually making it to a gynecologic oncologist? So we saw that in the data, definitely.

Mary Charlton:
My PhD student, Kristen Weeks, recently published a paper from that dataset, showing that people in rural areas, were more likely to present with ovarian cancer at stage four, advanced stage, compared to their urban counterparts. So we saw a lot of that in there. This year’s report, which I think, I don’t want to jump ahead too much to your other questions, but this year’s report is going to focus specifically, on cancer disparities by race. So that’s something that we’re going to be looking into very closely.

Mary Charlton:
Sometimes it’s difficult to do for selected cancers. Ovarian cancers one of them, we tend in Iowa at least, not to see a very large non-white population that gets ovarian cancer, but certainly in other cancers, there are some definite, likely disparities that we think we’ll find. And so we wanted to dedicate the whole report to the equity of what we see in cancer, both overall, and in the major cancers that affect Iowans.

Oge Chigbo:
All right. Thank you so much for that. How do you think the Iowa 2021 cancer report will look like? I mean the 2020 report listed 18,700 new invasive cancers. If you could make a prediction, do you think the pandemic might exacerbate or decrease this number? How might health inequity play a role in the distribution of these cases?

Mary Charlton:
Yeah, that’s a really good question. I think, two of the four of our big cancers in Iowa and in most states, are breast and colorectal cancer. And those are ones that are often diagnosed through screening exams, colonoscopies and mammography’s. So I think the pandemic has caused a lot of people to decide, “Unless I really need medical care for some kind of acute issue, I’m not going to the doctor.” So I guess if I had to make a prediction and I probably will, when we’re doing our next cancer in Iowa report, I would imagine that we will see a dip in our 2020 numbers for diagnoses of breast and colorectal cancer. Of course, that doesn’t mean that they’re not there.

Mary Charlton:
So I would imagine in then later years, as we come out of this blasted pandemic and people go back to the doctor and get their mammography’s and colonoscopies, that cancer will be detected. Unfortunately, I think it will be detected at a later stage. So that’s the fear, is that this delay of screening is going to put off diagnosis until a later stage when cancers get more difficult to treat. So I do think we’ll see either a leveling off or even a dip in our numbers and then a swift rebound, once people are going back to the doctor.

Oge Chigbo:
So then the numbers in the future, look like an increase in probably, mortality rates due cancer?

Mary Charlton:
Yep. And that’s something we’ll be watching very closely. And I think part of your question, also is about inequity and I think unfortunately, that will play a role, given the demographics of essential workers or people who already don’t have very good access to the healthcare system, either because of insurance reasons, mistrust reasons, unable to get off of work reason, all kinds of reasons. I think it will disproportionately affect the underrepresented minority populations, African-Americans, Latinx populations. I think we’re going to need to look at that very closely.

Mary Charlton:
And even now, even with the pandemic still going on, I think we need to do everything we can to encourage people to still get some of those screenings, understanding the risk is not zero of going to a healthcare provider, to have those done. So I think we have to think about the big picture, but knowing that the risk may be greater for people in terms of mortality, if they don’t get some of these select screenings and we don’t make sure that they catch the cancer, as soon as they can.

Oge Chigbo:
Then, when looking at cancer surveillance, especially in Iowa, do you think there’ll be a difference when you’re looking at, if the cause of that in a cancer patient was due to COVID-19? Or if they had COVID-19 and they died due to cancer, do you think there’ll be a difference in the way that this data is being reported, for cancers surveillance?

Mary Charlton:
Yeah, that’s a tricky question. I do really wish my mentor, Dr. Lynch were here because he is the, cause of death guru, when it comes to reporting and interpreting that. I do believe both cancer and COVID would show up on the death certificate, one being a cause of death, one being a contributing cause. I’m hoping that we can work with IDPH to be able to combine, maybe registries, of people who have had COVID and people who have had cancer, so we can do a really nuanced analysis of what’s going on with that. When we look at cancer mortality, we often look at overall mortality and cancer specific mortality.

Oge Chigbo:
Okay.

Mary Charlton:
So if there were a lot of people who had cancer that also got COVID, before they died of cancer, they may have been dying of cancer, but then got COVID and so that became the cause of death. We’d still know that they had the cancer, and so it’s trying to figure out how to account for that and to adjust for some things, to see how that all played out. But it’s really interesting and I would love to talk to people in immunology and infectious disease, to really understand.

Mary Charlton:
Some of the issues that killed people with COVID, was this intense immune response and sometimes that got out of control. So what does that look like in immuno suppressed person? Are they protected from that, but then because they’re so immune suppressed and the virus just gets out of control and works in other ways? That I’m not sure and I think there’s a lot of studies going on right now, related to both cancer and COVID. So I’m hoping that as more studies emerge, we’ll understand how best to analyze that. But I think that’s a really good question and one we’re going to have to be thinking about in the coming years.

Oge Chigbo:
Yes. All right. Thank you.

Emma Meador:
Oh, that was very interesting. Thank you for sharing. And I would just like to give you another congratulations on receiving a grant to collaborate with the Iowa Department of Public Health on an ovarian cancer study. Can you share a little bit about what this research is entailing?

Mary Charlton:
Sure. I already talked a little bit about how, it seems like in Iowa, there’s a fair amount of people, not an overwhelming majority by any means, but still not zero, still a substantial percentage of women in Iowa who never get to a gynecologic oncologist, for particularly surgery, for their ovarian cancer. So we’re working with the Iowa Department of Public Health and a couple other sites that were awarded the same grant, to figure out what strategies would mitigate this issue.

Mary Charlton:
So again, my PhD student, Kristen Weeks did some interviews with both, OB GYN providers and some hospital administrators and then also, patients who, we could see from our cancer registry records, that it looked like they never went to a hospital that had a gynecologic oncologist. So we were able to recruit those women who were still alive. We certainly didn’t want to make them feel during those interviews, like they did the wrong thing. So we didn’t come out and say, “Why did you not go to a gynecologic oncologist?”

Mary Charlton:
But we talked more about, “How did you make your decision about where to go and what factors played into that and what barriers did you have in getting care?” And different things like that, and it was really interesting between the provider interviews and the patient interviews. The providers perceived, especially, rural and older patients, would have all kinds of trouble getting to a large, academic medical center, like the University of Iowa, because six of the seven gynecologic oncologists, we have in the state are here and one of the seven is in Des Moines. So they’re only located in large urban centers.

Mary Charlton:
So a lot of the referring providers thought, “Well, it would be too hard for them to get there. They’d be overwhelmed. It’s just that there was a lot of logistic challenges for them.” But then when we asked the patients in our roundabout way, to make sure that they didn’t feel like we thought they did anything wrong, they basically came out and said, “I went wherever they told me to go and I didn’t have any barriers. And if they would have told me to go somewhere else, I would have gone somewhere else.” Basically. So they put a lot of trust into that referring provider and trusted that that person was going to send them to the very best place where they could get care.

Mary Charlton:
So they just never really questioned it. And they didn’t say, “I wouldn’t have gone to the University of Iowa, it’s too big, or I wouldn’t have gone to the Mayo.” They don’t say things like that, or, “I couldn’t have traveled, or my insurance wouldn’t have covered it.” We specifically asked about some of those barriers that the providers had mentioned and they said, “No, I could have done whatever I needed to do.” That was interesting.

Mary Charlton:
So we’re trying to take what we learned from that and develop some education materials, both for patients and for those referring providers to say, “Here’s what we learned through talking with patients. They really need a strong recommendation to go to see a gynecologic oncologist for these myriad of reasons, and here’s how you make the referral.” We’ve tried to work with the people here and in Des Moines to really understand that process, in case that was where the perceived holdup was, that there was some kind of issue with the referral process. So we’ve tried to educate them about that.

Mary Charlton:
And then, we’re doing a series of CME webinars, both OB GYNs and primary care providers across the state, could take to learn more about, “Why is it so important to refer ovarian cancer patients, to gynecologic oncologists?” Talking about the interviews that we did, different things like that, to really educate them. So those are the main strategies that we’re employing through that grant.

Oge Chigbo:
All right. Thank you so much for that. Actually, that was really detailed, which I bet were all right.

Mary Charlton:
Exactly.

Oge Chigbo:
This one we just did. The next question is, what is the most pressing issue within your field, you would like to solve?

Mary Charlton:
Wow, that’s a hard question, but I think for me, and just for my whole area of research, I think about how we spend, our country invests billions of dollars to figure out, “What is the best course of care for cancer patients?” How much money we spend on drug trials and all different types of clinical trials and observational studies to figure out, “What is the standard of care for cancer patients?”

Mary Charlton:
So what I would like to solve is, if we’re going to spend all the time, money, effort, everything, to invest in, “What is the right thing for them to get?” And we need to figure out, “Why people then don’t get it?” So the next step of where do things break down? And why doesn’t everybody get what they’re supposed to get, after we’ve invested all the time and effort into doing the research, to figure out what they’re supposed to get?

Mary Charlton:
So that’s really what I would like to solve is, where are those breakdowns and why does it differ by population and what can we do to reduce those barriers and make it so that everybody can get what they’re supposed to get? And if they choose not to, for their own personal reasons, then that’s fine. I always want them to have the option to get what they should be getting.

Emma Meador:
Thank you. I think that’s a great answer and a topic that definitely deserves a lot of attention and more recognition than what it has. So thank you for that. And then our last question is, what is one thing you thought you knew, but was later wrong about?

Mary Charlton:
There are about a zillion of those, but I focus it on cancer epidemiology, along the lines to what I was just talking about. I guess when I went into this and started some of my earlier studies, I just thought that people who have been diagnosed with cancer, want all the information that they can possibly get, so that they can make an informed decision. I thought they’d be running to the internet, asking around, getting second opinions, doing everything they can to get all the information that they need to make the best decision for them.

Mary Charlton:
And I learned, I was very wrong about that. There are some populations who do that, and I specifically, think of breast cancer patients, there’s a ton of information online. There’s a lot of support groups and support structures and everybody’s Komen, and there’s a lot of awareness about that. Also, just the demographics of women who get breast cancer, they tend to be upper socioeconomic status type people, and a little bit younger than a lot of the other patients with other types of cancer, so they’re a little bit of a different group.

Mary Charlton:
But outside of breast cancer and particularly what I study, one of the cancers I study a lot is, rectal cancer and ovarian cancer. Recently, I’m hearing from both of those groups, that they’ve just been given a really overwhelming, devastating cancer diagnosis. They don’t want to go online. They’re afraid they’ll be scared by what they see out there. They just want to know that that person who told them they have cancer, is going to send them to the best place where they need to go and people are going to handle it from there because they think, “Well, I don’t know anything about this cancer, but hopefully these people do.” They just put all their trust in that referral system to get to the right place.

Mary Charlton:
And they’re not as interested in going and doing a lot of research or getting a lot of second opinions or questioning the opinion of their doctor, or asking, “How many of these procedures do you do a year?” And those types of things. The main demographic of the older population who get cancer, aren’t going to do those things and don’t want to do those things. So while I still really believe in the area of research and the need for more research and patient engagement and helping people make informed decisions and shared decision-making, where I’ve sort of landed in my research is, I really want to have an impact on that referral process because I don’t think people understand how it actually works.

Mary Charlton:
I’m sure doctors understand that people are really relying on them, but may not know how little outside activity they’re doing beyond that referral. They’re essentially, mostly directed to these places by them. So I want to help influence that process and make sure that the rural complex patients and the patients who would really benefit from coming to places like the University of Iowa or Mayo, for a really hard surgery, can do that and know that they should do that.

Mary Charlton:
On the flip side, a lot of providers have said, “I refer my patients to places like the University of Iowa and I never see them again, they’re gone, they don’t come back. That’s hard for them to travel and get all their care there, they’d be happier locally.” So I do think that hospitals need to work together more and send those patients back then, so they can get chemotherapy and radiation close to home, where their family can support them, or they don’t have to travel as much. And I think all that communication between health systems is not ideal right now and does not support that.

Mary Charlton:
So that’s the area that I am trying to get into with my research is, “How can we extend the resources and expertise here, at places like the University of Iowa to help make local hospitals better.” Build that trust relationship between them, so that they’re referring the right patients here and we’re sending them right back, so they can get a lot of their treatment close to home.

Oge Chigbo:
All right, thank you. So from what you were saying, or what I was hearing, and it seems like you’re really interested in social determinants of health aspects of getting the patients, the care that they need and looking at other factors that might affect why they are not going there in the first place?

Mary Charlton:
Right.

Oge Chigbo:
I think we need more of that actually, because most people don’t really know how the role, that social determinants of health, plays in all our lives and the huge impact, any health outcome at all.

Mary Charlton:
Right.

Oge Chigbo:
Yeah. Thank you for talking about that. I think that was the last question. Yeah, that’s the last question that we have on our list. Thank you so much for coming on the pod today.

Mary Charlton:
Sure.

Oge Chigbo:
It was interesting to hear what you’re working on and what you’ve worked on and what you will be working on.

Mary Charlton:
Thanks. Thanks for inviting me. It’s always nice to talk about my area of interest and hopefully inspire some people maybe, to come down the same path that I have, because it’s been a great area of research and there’s just so much opportunity and so much need for it.

Oge Chigbo:
Yeah.

Mary Charlton:
So I hope others will join me and contact me if they have any questions or want to learn any more.

Emma Meador:
So that’s the end of the episode for today. Thanks again to Dr. Charlton for taking the time to come on the pod this week. We hope you find this podcast as informative and interesting as we did.

Oge Chigbo:
All right. So talking about how interesting this podcast was, Emma, what did you think?

Emma Meador:
Yeah, I thought this was such an informative interview. I didn’t know a lot about cancer epidemiology and the rates of it within Iowa. I thought it was so interesting to hear that. And also, just how they really look for those disadvantaged populations and groups of individuals and see how they’re receiving cancer care and their thoughts of it, so they can really improve upon all of those inequalities and disadvantages, people are facing. So really everyone, no matter their socioeconomic status, can have the same care of cancer treatment that they all deserve. So I thought it was so interesting and informative.

Oge Chigbo:
Right? Same, I also really enjoyed the part where she talked about reporting the survival rates of cancer patients. I think that’s a hopeful glance or a hopeful way to look at it, because usually it’s incidents, prevalence, mortality. You never see, “Okay, how many people actually survived?” So that one actually really struck out to me. And then when she then started to talk about her research on what she hopes to see, and then talking about the whole social determinants of health, which I think, okay, so for our listeners who don’t know what that means. Social determinants of health is conditions in which people are born into, you live, you work, you play.

Oge Chigbo:
So where you live, the kind of support system you have around you, just all the little things, you probably don’t really pay attention to. Well, how do all those factors come together to affect your own health outcome? So I think that’s something even in medicine, we need to really look at, because once someone comes into the hospital for a treatment, at that moment, you give them what they need, but then they go back to the same environment that they were in, in the first place. So then they’re coming back again for the same exact thing. So I definitely think that’s worthwhile and it’s very interesting.

Emma Meador:
I agree. I think that’s a great point you brought up. I also thought it was so interesting, how she was talking about, in the future reports for next year’s and probably a couple of years on, there’ll be looking at the correlation of COVID-19 and how COVID-19 has affected not only cancer rates, but the morbidity and mortality of them? So I think that’ll be very interesting to look at in future years.

Oge Chigbo:
Yeah. I wonder how that’s going to look actually? I’ve just feel that’s way more work, but we’ll see. We’ll see, I hope it goes good. I hope it’s not as bad as we’re seeing. So all right, we’re out of here. So you can find us on Facebook at the University of Iowa College of Public Health or on iTunes and Spotify, as well as the University of Iowa College of Public Health.

Emma Meador:
Let us know what you thought about this episode in series, at cph-gradambassador@uiowa.edu. That is C-P-H-G-R-A-D-A-M-B-A-S-S-A-D-O-R @uiowa.edu. This episode of, From the Front Row, was hosted by Oge Chigbo and Emma Meador. This episode was written by Oge Chigbo and Emma Meador. It was edited and produced by Steve Sonya.

Oge Chigbo:
Thank you, Dr. Charlton for coming on the pod this week. This podcast is brought to you by the University of Iowa College of Public Health. See you next week, happy social distancing, stay safe, and always remember to have that uncomfortable conversation.