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Happy Friday. And welcome to Cornhole Champions. I’m Zachary Oren Smith. It’s Friday. And this newsroom is laser focused on our new cancer investigation, The Hot Spot. There’s reporting that needs doing. Instagram carousels that need formatting. And videos—like this one—that need editing.
In some ways, our work in this space only exists because of the work already assembled each year by the Iowa Cancer Registry. Since its inception in 1973, it’s been measuring incidence, survival and mortality of cancer among Iowans. Every year, the new report is a splashy release among media sources because it tends to take a trend from the data and explore the state. The stat that we keep harping on—that Iowa has the 2nd highest rate of cancer in the nation and fastest growing—comes from this report. But like most headlines, it only tells part of the story.
This week, I sat down with Dr. Mary Charlton. She directs the Registry, and she helped me dig into what this data tells us—and what it doesn’t. What emerged was a conversation about the messy reality of trying to understand a diagnosis as complex as cancer in a world that wants simple answers.
Watch the full conversation on our Youtube. Here are some interesting moments from the interview.
The problem with a simple story
When you look at Iowa’s cancer rates county-by-county, a pattern does emerge. But may not be what you expect.
We see our highest rates of melanoma generally in the northern tier of counties. Meanwhile in the southern tier, lung cancer rates are the highest. If you look at prostate cancer, the highest rates are west and northwest. Breast cancer rates are highest in urban areas. Colorectal cancer is highest in rural areas.
“It's kind of further proof that there is not one thing that's causing cancer in Iowa. It just can't be, or we wouldn't see all these different patterns and different types of cancer,” Charlton said. “I think it's just cancer's really complicated. The risk factors all work together to alter your cancer risk. “
Fights over the wrong question
The Registry's 2024 report featured alcohol as a risk factor, noting that less than 40% of Americans know alcohol is a carcinogen. The choice made sense: Iowa has high binge drinking rates and high rates of alcohol-related cancers.
"The overwhelming response was people saying thank you for the report, I really didn't know," Charlton said. But there was pushback too: "How can you be talking about alcohol when everybody knows it's the nitrates or the pesticides in the water?"
This tension—pitting one risk factor against another—frustrated Charlton.
"Addressing any one risk factor is not gonna help us that much. We have to talk about all the risk factors,” she said.
Science is a long slog
For me, the most interesting part of the conversation was Charlton talking about the difficulty of linking environmental factors to cancer. Cancer develops over years. People move. Exposures change. And even the pesticides that might have common once, aren’t the same ones being used today.
"We don't have the types of data that you can follow over time that have an accurate exposure for everybody to then look at cancer as the outcome," she said.
This doesn't mean environmental factors don't matter or should be studied. On the contrary, studies like the Agricultural Health Study, which has followed 30,000 pesticide applicators since the 1990s, are producing important results. And next week, we’ll have a full letter devoted to it. (Make sure you sign up.) But it means the work is slow, complex, and doesn't offer the clarity people desperately want.
"Unfortunately we're (The Registry) a giant disappointment to most people who would like us to just say, why can't you figure out what's causing all the cancer in Iowa?" Charlton said. "We would love to be able to do that, but we have to work with lots of partners and it's gonna be a long, slow slog."
Funding our future
The registry faces an uncertain future. Federal funding provides the majority of their budget and it was recently cut by 35%. Charlton said, for a time, Iowa almost lost its cancer registry entirely.
"When you think about things like cancer prevention, there's not really anyone else to fund that," Charlton said. "The drug companies can't come in and save us... that's not their goal, that's not their bottom line."
It's a sobering reminder that the infrastructure we need to understand public health challenges doesn't maintain itself.
What this means
Iowa's cancer story is complicated. It resists simple narratives and easy solutions. And that's frustrating for people who want action. It was clear to me that Charlton gets that frustration. When you're facing a potentially deadly diagnosis, you want answers.
But maybe the complexity is the point. Maybe accepting that cancer has multiple causes—environmental, behavioral, genetic—opens up more possibilities for prevention than clinging to any single explanation.
The Registry's job isn't to provide the answers we want. It's to provide the data we need. And after 50 years of collecting that data, the picture that emerges isn't simple. But it is real.
You wrote in
This week, I asked you why you live here; what keeps you here? Your responses reminded me why this state is worth fighting for:
Jennifer from Iowa City: My grandmother lives outside Kalona. She’s 89 and still make me dinner most Sundays. I could move to Chicago tomorrow for a better job, but who’s going to argue with her about using too much salt on the green beans. She keeps me rooted here.
ZOS: There’s a magic to a routine. An inertia. And there’s a magic to the people who’ve watched us grow into ourselves. That’s a really special relationship.
Mark from Cedar Falls: “Honestly? It’s a short commute. My kids walk to school. We know our neighbors. I grew up in Denver and spent my twenties in Portland trying to find myself. But it turns out, proximity is what I needed.”
ZOS: Short commutes are underrated until you lose it. Covering the Legislature last spring, I was regularly driving from Iowa City to Des Moines. Put a number on my nerves. FR, proximity is everything.
To everyone who wrote in about the people, places, and rhythms that keep you here—thanks. You make this newsletter and this state a place I want to live.
Before you go
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Cornhole Champions is a weekly podcast powered by Iowa Starting Line with music by Avery Mossman and show art by Desirée Tapia. We are a proud member of the Iowa Writers Collaborative.
Your friendly neighborhood reporter,
Zachary Oren Smith
Political correspondent
Iowa Starting Line
