A Completely Normal Number of Charts
Dustin Osborne • April 7, 2026
This is way too many charts for a random Tuesday, but I think this highlights the issue in Appalachia and certainly other similar corridors in the United States.
ARC · Appalachian Radiotheranostics Coalition
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Data & Evidence — ARC Corridor
Tennessee · North Carolina · Virginia · Appalachian region
The disparity,
by the numbers
Cancer burden, screening access, survival outcomes, and theranostics infrastructure gaps across the ARC corridor states: East Tennessee, Western North Carolina, and Southwest Virginia, with regional context from Appalachian Kentucky.
Cancer mortality by state — Appalachian counties
The corridor states carry a measurable excess burden over the national average
Age-adjusted cancer mortality in the Appalachian counties of Tennessee, North Carolina, and Virginia runs consistently above the national rate, with Southwest Virginia approaching the highest-burden levels seen in Central Appalachia. These are the communities the ARC corridor is built to serve.
Age-adjusted cancer mortality — Appalachian counties by state (deaths / 100,000)
U.S. national average (168)
East Tennessee Appalachian counties
Western NC Appalachian counties
SW Virginia Appalachian counties
Appalachian Kentucky (context)
Sources: NCI State Cancer Profiles · CDC WONDER age-adjusted mortality 2016–2020 · Appalachian Regional Commission Health Disparities Report
East Tennessee
+14%
Above national average in Appalachian TN counties: ARC's anchor region
Western North Carolina
+11%
Above national average: WNC counties among the most rural in the Southern Appalachians
Southwest Virginia
+22%
Above national average: coal country counties approaching Central Appalachian burden levels
Appalachian Kentucky
+35%
Above national average: highest burden in the region, context for the full Appalachian spectrum
Cancer-specific mortality — corridor states
Lung and colorectal cancers drive the excess across all three corridor states
The cancer-type breakdown reveals that lung, colorectal, and cervical cancers, all addressable through earlier detection or targeted therapy, account for most of the excess mortality in TN, NC, and VA Appalachian counties. Prostate cancer mortality in these counties is the direct target for PSMA-based theranostics.
Estimated cancer mortality (deaths / 100,000) — ARC corridor Appalachian counties vs. national average
U.S. national
East Tennessee
Western NC
SW Virginia
Sources: NCI State Cancer Profiles · CDC WONDER · ACS Cancer Facts & Figures 2024 · NCI Appalachian cancer data
In the Appalachian areas of Ohio, Kentucky, Pennsylvania, Virginia, and West Virginia, rates of lung, cervical, and colorectal cancer incidence and mortality are higher than anywhere else in the United States. Tennessee and North Carolina follow closely.
NCI, Addressing Cancer Disparities in AppalachiaScreening rates — corridor states
Screening gaps vary by state — and corridor states fall short
Tennessee, North Carolina, and Virginia all have Appalachian counties with below-national screening uptake whic is the entry point for late-stage diagnoses that limit treatment options and theranostic eligibility. The specific gaps differ by cancer type and state.
Colorectal, lung CT, and cervical screening rates — Appalachian counties vs. state average and U.S. national (%)
Sources: Hudson et al. J Rural Health 2024 · CDC BRFSS State Data · TN, NC, VA Department of Health cancer reports · ACS guideline benchmarks
TN
Smoking — Appalachian TN
24 %
vs. 12% nationally and 22% statewide. East Tennessee counties carry above-average smoking rates that drive lung and head/neck cancer burden
NC
Colorectal screening — Western NC
−9 pp
Below national colorectal screening rate in Western NC Appalachian counties which are among the largest geographic screening gaps in the state
VA
Cervical screening — SW Virginia
−13 pp
Below national cervical screening rate in Southwest Virginia which contributes to the region's elevated cervical cancer mortality relative to the state average
Historical trend
The gap has widened across the corridor
The 50-year divergence is most extreme in Appalachian Kentucky, but Tennessee and Virginia Appalachian counties show the same directional pattern. Progress against cancer has been slower and smaller in these communities across every decade since 1970.
Cancer mortality trend — U.S. national vs. ARC corridor states (Appalachian counties) · indexed 1970 = 100
U.S. national
East Tennessee
Western NC
SW Virginia
Appalachian KY (context)
Sources: Hudson et al. J Rural Health 2024 · NCHS Compressed Mortality File 1968–2018 · NCI SEER · ARC Health Disparities Report
5-year survival — corridor states
Survival deficits are measurable in Tennessee, North Carolina, and Virginia
Appalachian counties in all three corridor states show lower 5-year survival for the major cancer types, reflecting later-stage diagnosis, longer time to treatment, and limited access to advanced therapies including theranostics. These are not Kentucky-specific statistics.
Estimated 5-year cancer survival — Appalachian counties vs. urban non-Appalachian counterparts (%)
Urban non-Appalachian (comparison)
Appalachian Tennessee
Appalachian NC
SW Virginia
Sources: Zahnd & Ganai PubMed 2016 · SEER-18 Program · Burus et al. JACS 2025 · TN, NC, VA state cancer registries
TN
Appalachian TN — all cancers
−6 pp
5-year survival gap between Appalachian Tennessee counties and urban non-Appalachian counterparts or roughly 6 percentage points across all sites
NC
Western NC — all cancers
−5 pp
5-year survival deficit in Western NC Appalachian counties and is a smaller gap than TN and VA, but consistent across cancer sites
VA
SW Virginia — all cancers
−9 pp
Largest 5-year survival gap among the three corridor states where Southwest Virginia's coal-country counties approach the outcomes seen in Appalachian Kentucky
Program geography — ARC corridor
Two anchor programs at the corridor endpoints — and a gap in between
Molecular Imaging and Theranostics Research Program (MITRP) at UT Medical Center anchors the southern end of the corridor in Knoxville. Carilion Clinic anchors the northern end in Roanoke. Western North Carolina, Southwest Virginia, and Upper East Tennessee sit between them with high-burden communities and limited local RLT support.
Approximate cancer mortality burden by county — ARC corridor states (deaths / 100,000, 2016–2020)
Sources: NCI State Cancer Profiles · CDC WONDER 2016–2020 · ARC corridor county mapping
The counties with the highest cancer burden in the ARC corridor are the same counties without active theranostics programs. Between Knoxville and Roanoke lie communities that have the nuclear medicine infrastructure, but not the trained workforce, to use it.
ARC Program Assessment · Mittra et al. PubMed 2024 · Avalere Health 2026Active theranostics programs — ARC corridor
2
MITRP at UTMC (Knoxville, TN) and Carilion Clinic (Roanoke, VA): the two anchor institutions of the ARC initiative
Community hospitals between anchors — without RLT programs
6 +
Major community hospitals in the Upper East TN, WNC, and SW VA corridor currently without an active theranostics program
Estimated corridor patients eligible for Pluvicto / Lutathera
Hundreds
annually
annually
Who currently lack a local program and must travel to Knoxville, Roanoke, or out-of-corridor for therapy
Infrastructure readiness — corridor community hospitals
The hardware is there. The operational infrastructure is not.
Community hospitals in the TN–NC–VA corridor have made real investments in nuclear medicine. Most have SPECT/CT. Most have nuclear medicine departments. What they lack is the Authorized User, the dosimetry capability, the shielded suite, and the billing knowledge to convert that foundation into an active RLT program.
Community hospitals — ARC corridor (TN, NC, VA) — estimated % with each program component
Bars show estimated % of community hospitals in the TN–NC–VA ARC corridor with each component. 100% = required for a functioning RLT program. Sources: Mittra et al. PubMed 2024 · Avalere Health 2026
Workforce pipeline
Workforce supply vs. near-term demand — the constraint ARC is targeting
Authorized User certification is the hardest gap to close, and it is most acute in community and rural settings. The ARC education initiative directly addresses the referring provider knowledge gap and the operational training gap, the two constraints most responsive to intervention on a one-year timescale.
Estimated workforce supply as % of projected near-term demand (demand = 100%) — community settings
Sources: The Radiology Review 2024 · Lancet Oncology workforce analysis 2024 · ASRT 2024 Consensus Report · ABNM certification data
NM physician certifications per year vs. RLT demand growth — the scissors gap
NM physician certifications (est. per 5-yr)
RLT demand index
Source: ABNM — 5,907 total certifications 1972–2020 (~123/yr avg) · ASRT 2024 Consensus Report
ARC providers to be trained — corridor goal
25 +
Community-based nuclear medicine professionals and referring providers across TN, VA, and the corridor: SNMMI Mars Shot grant target
In-person workshops — year 1
4
Two at UTMC in Knoxville, two at Carilion in Roanoke, targeting providers at both ends of the corridor with hands-on, case-based training
GEP-NET burden — corridor states
Neuroendocrine tumors: rising incidence, undertreated across the corridor
Lutathera (177Lu-DOTATATE) addresses somatostatin receptor-positive GEP-NETs which is a diagnosis with rapidly rising incidence and strong outcomes when treated early. In Tennessee, North Carolina, and Virginia, provider awareness of PRRT eligibility criteria is low, and somatostatin receptor imaging access is limited outside the anchor institutions.
U.S. GEP-NET incidence — age-adjusted rate per 100,000 (1975–2020)
Sources: Dasari et al. JAMA Oncology 2017 · SEER Program · Singh et al. NETTER-2 Lancet 2024
U.S. NET incidence growth since 1973
6×
GEP-NET incidence has grown more than sixfold in 50 years, a rapidly expanding eligible population for PRRT
GEP-NET 5-year survival — localized vs. distant
97 vs
25 %
The survival stakes of early vs. late detection, making timely somatostatin receptor imaging access a high-value intervention
Eligible GEP-NET patients currently receiving PRRT
<30 %
Of the estimated eligible U.S. population with advanced GEP-NETs; access barriers mirror those seen in prostate cancer theranostics
By Dustin Osborne
•
March 31, 2026
Appalachia’s cancer burden is higher, but theranostics access lags: distance, workforce shortages, and referral gaps still shape who gets care.
By Dustin Osborne
•
March 24, 2026
Don’t let referral myths block care: this guide shows when to send patients for Pluvicto or Lutathera and what clinical signals should prompt early action.
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