‘A Perfect Storm:' Struggles and Hopes for Mississippi Oncs

It's not because there are bad doctors in the state, said Otis Brawley, MD, professor of oncology and epidemiology at the Kimmel Cancer Center at Johns Hopkins University, Baltimore. 'It's a combination of the environment that people grow up and live in,' plus obesity, poor eating habits, and overuse of alcohol and tobacco, all of which significantly increase cancer risk, he told Medscape Medical News .
In Mississippi, rates of smoking and alcohol consumption are higher than the national average, while physical activity and fruit and vegetable intake remain low.
Income, education, comorbidities, and the state's healthcare infrastructure all also play a role.
Residents have high rates of chronic diseases and comorbidities, such as diabetes and high blood pressure. And with median household incomes nearly 38% lower in Mississippi than the national income, healthcare can take a backseat to the basics — food, clothing, and shelter.
For many, it can be a struggle to keep the lights on or keep their children in school, explained Jimmie Wells, RN, MSN, OCN, a long-time oncology nurse, navigator, and educator who recently retired from academic medicine.
'There are a lot of people that are just in survival mode,' said Wells, who volunteers as the Statewide Coalition Chair for the Mississippi Partnership for Comprehensive Cancer Control. 'They get up and ask themselves, 'what am I going to eat today? Are my children going to eat today?''
These issues are compounded by Mississippi's overall healthcare infrastructure and performance. The state consistently ranks near the bottom in access, quality, disparities, and outcomes, the Commonwealth Fund reported in 2023. Mississippi is also one of 10 states that did not expand Medicaid under the Affordable Care Act and, not coincidentally, has some of the worst cancer outcomes, said Brawley.
Access to care is a particular challenge.
Because the state is so rural, once someone is diagnosed, 'it's hard to get to good care,' said Brawley.
All 82 counties in Mississippi are considered medically underserved , either entirely or partially, by the Health Resources and Services Administration. And although estimates vary, the American Society of Clinical Oncology counts 151 oncologists practicing in the state, which includes 34 radiation oncologists and three surgical oncologists, according to data provided to Medscape Medical News .
'There are not enough providers,' especially in rural areas, Wells said. 'It is absolutely an issue.'
Plus, Brawley noted, 'there are very few doctors willing to move into Mississippi to practice medicine.' From Beijing to Jackson
Qu, however, was eager to practice in Mississippi. As a medical student at Peking University in 1989, Qu joined a million fellow students in Tiananmen Square who were demonstrating against the Communist regime. When the military opened fire on the protesters — killing hundreds and injuring thousands — Qu decided it was time to leave China.
He studied English and was accepted to a cancer genetics graduate program at Tulane University Medical School in New Orleans. As it ended, he decided he wanted to go into practice. He was matched to the University of Mississippi School of Medicine, Jackson, Mississippi, and he fell in love with Mississippi.
After medical school, Qu pursued a fellowship in hematology and oncology, landing a position at the Mayo Clinic in Rochester, Minnesota. While he could have stayed at Mayo, he decided to move back to Mississippi to practice. He believed his contribution at Mayo would 'be very, very minimal,' but he could make a relatively large impact in Mississippi.
It's a different world in Mississippi. High rates of comorbidities and socioeconomic factors weighing on residents lead to delayed diagnoses.
'Our colon cancers are diagnosed in the emergency room,' Qu said, noting that patients often come in with an obstructed or perforated bowel. 'We see this every day,' he said.
Jackson Oncology has been recognized by the American College of Surgeons for its quality and outcomes, but with people seeking care so late, 'unless you are God, we cannot cure that person,' said Qu.
His practice has also been hobbled by low reimbursement, especially from Blue Cross Blue Shield, which pays less than Medicaid. Plus, 10.5% of people lack health insurance.
Although challenging, Qu said, 'we are finding ways to keep our door open.' Home of the Blues
The Mississippi Delta is famous worldwide for being the birthplace of Blues music. That was top of mind for Syed Rafique, MD, when he made the decision to practice in Greenwood, at the western edge of the Delta.
It was not his first choice, and friends and colleagues advised against the move. But a recruiter convinced the Pakistani-born physician — who had completed internal medicine and hematology/oncology residencies at SUNY Health Science Center in Brooklyn, New York — that the Blues lover would enjoy seeing live music at the still-existent juke joints that peppered the Delta region.
At that time, in 1994, there were no oncologists between Jackson, some 100 miles south, and Memphis, 130 miles to the north, said Rafique. People in the Greenwood area couldn't afford to go to those cities for diagnosis or treatment, he said.
For Rafique, that was a reason to go to the Delta. 'I didn't want to have to fight for a patient in New York or another big city,' he told Medscape Medical News .
Like Qu, Rafique felt like he could help more people in Mississippi. He agreed to stay for 5 years. But then he never left.
Providing cancer care in the Delta region is especially challenging, Rafique said.
While cancer incidence in the Delta is on par with that in the state, the Delta has the highest overall cancer mortality. At about 200 cancer deaths per 100,000, it is 13% higher than any other region, according to the state health department. Deaths from prostate cancer are particularly high at about 34 per 100,000 men (vs about 25 in the state overall), as are deaths from lung cancer at 55.5 per 100,000 (vs 47.5 in the state).
Rafique sees around 40 patients a day, which is well above the norm. He has had to sell stock holdings to cover the cash flow for his practice, especially with delays in insurance approvals for expensive medications.
He sometimes wonders if he can keep practicing, but he knows that not many clinicians are looking to come to Mississippi to replace him.
Just a handful of oncologists practice in the Delta. Rafique and a radiation oncology colleague are the only cancer specialists at Greenwood Leflore Hospital, Greenwood, Mississippi, a 25-bed facility that serves 300,000 residents. Out of the 11 hospitals in the region, six are scaled-down facilities without full specialty offerings or inpatient care.
That means specialty care often requires travel to Jackson or Memphis. But that is not realistic for everyone. Patients are older and cannot drive, Rafique said. 'They cannot leave Greenwood.'
Poverty also drives many decisions.
Some patients stop taking medications in the face of multiple denials by insurers, Rafique said. Others stop coming to see him because they can't afford to pay for gas.
One day, Rafique saw a man in his 60s with neck pain. A scan revealed a spinal tumor — what appeared to be a metastasis. After determining the primary disease was hormone receptor-positive breast cancer, the oncologist proposed tamoxifen — a pill — to treat the cancer. A relatively simple plan.
But the patient and his family refused treatment because his job was allowing him to pay a big premium on a life insurance policy that he hoped would sustain his family after his death.
It was a stark dilemma. 'I can prolong his life, but he won't be able to work and won't be able to pay the premium for his life insurance, and then he will lose the life insurance,' said Rafique.
The patient chose to go into hospice.
'When I came to Mississippi, I was shocked,' said Rafique. Now, he realizes there 'is only so much you can do.'
'It's like a perfect storm,' he said. 'It's not one thing that you can go and pinpoint and fix.' Seeing Light in Darkness
Despite the hurdles, efforts are underway to give Mississippians better care.
The Office of Mississippi Physician Workforce and the Mississippi Hospital Association have been working to bring more doctors, including residents and fellows, to the state, especially in rural areas.
The Mississippi Partnership for Comprehensive Cancer Control— a group of more than 100 organizations, including the American Cancer Society — is working to improve access to cancer care, preventative services, and screening as well as engage Mississippi residents.
In 2024, the Partnership went to barbershops to talk about prostate cancer, which disproportionately affects Black men. Another recent effort has involved bringing a mobile clinic to conduct pap smears to 'hot spots' around the state, Wells said.
Mississippi Baptist Medical Center and the Baptist Health Foundation have also deployed m obile mammography units to three areas in Mississippi. However, Wells explained, questions surrounding who will pay for the exams has limited the rollout.
When it comes to community engagement, there's no one size fits all approach. Wells has found engaging Mississippians is a hyper-local enterprise that requires many different avenues of outreach. Every community has 'a different rhythm, a different kind of culture,' she said.
Despite the challenges, Qu and Rafique said they wouldn't practice anywhere else.
Rafique calls the Delta home. 'I love my work. I love these patients,' said Rafique.
Like Rafique, Qu also really, really loves this place.
Qu and his wife raised their four children in the state. Those children — two in residency, one in medical school, and one aiming to enter medical school — all plan to come back to Mississippi to practice. 'I plan to retire here and probably die here,' said Qu.
Qu goes to work every day knowing he can make a major impact. 'We generate miracles every day,' he said.
Alicia Ault is a Saint Petersburg, Florida-based freelance journalist whose work has appeared in many health and science publications, including Smithsonian.com. You can find her on X @aliciaault and on Bluesky @aliciaault.bsky.social. Lead image: Moment/Getty Images

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