The Journal Gazette, 600 W. Main St., Fort Wayne IN

Intense, solemn Ray Romines spoke with an audible heaviness in his voice, managing a stoic smile.

His intermittently wet eyes betrayed the fears of a life interrupted. Cancer is a scary ordeal, he said, sitting at the kitchen table in his New Haven home. “You don't know what to do or where to go.”

When he was diagnosed with advanced-stage lung cancer a year and a half ago, Romines, now 63, was given five years to live - if everything went right. That's longer than his neighbor lasted, he said, gesturing toward a nearby house on Sunnymede Drive. Like most people with lung cancer, his neighbor died within a year of diagnosis.

Faced with his own mortality, Romines has been somewhat paralyzed by indecision. He's not sure how he should fill his days.

Shortly before he found out he had cancer, Romines completed his associate degree in construction technology at Ivy Tech Community College. He planned to join his son's heating and air-conditioning business after he retired from making pistons for cars and light trucks at KUS in Fort Wayne. He'd wanted to wait a few years until his Social Security benefits kicked in to make the switch.

Instead, after he found out about the cancer, he quit working altogether. (His wife, Kathy, works third shift at Wal-Mart.) And he essentially put major life decisions on hold. “I'm just going to wait and see how things go this winter,” he said on a crisp November day.

Others living in Romines' ZIP code face their own battles with the disease that kills more people in the U.S. than any other cancer.

Adjusting for age, lung cancer has afflicted more people per capita in ZIP code 46803 - on Fort Wayne's east side - than in any other city ZIP code, according to figures the Indiana State Department of Health gathered for The Journal Gazette. The state said 46803, a working-class tract that extends into New Haven's west side, had 115 reported cases from 1995 to 2005.

A ZIP-code-by-ZIP-code breakdown revealed that the poorest, least-educated ZIP codes in Fort Wayne had the highest lung cancer rates. Given that higher poverty levels and less education usually coincide with higher smoking rates, health officials believe smoking is the most likely culprit. But others contend less prominent causes might be to blame.

Other suspects?

Romines quit smoking in 2006 after he was diagnosed with cancer. He still craves cigarettes sometimes, after meals and when he wakes up in the morning. He even dreams about smoking on occasion.

But he resists temptation - a tall order after nearly a half-century of smoking. “I might have started when I was 12 or 13. … It made you seem grown up,” he recalled.

Despite the strong link between smoking and lung cancer - almost nine of 10 lung cancer deaths are smoking-related - Romines' thoughts about what may have caused his cancer drift away from cigarettes. He thinks often about the potential consequences of chemicals deposited at a hazardous waste dump on Adams Center Road about a mile away.

Chemical Waste Management stopped accepting waste in 1998, but Romines wonders whether there could be lingering health effects for those in the surrounding area. Although the dump is closed, the Indiana Department of Environmental Management requires Chemical Waste to monitor groundwater at the site for certain contaminants and report to the agency.

To date, no contaminants have been detected, said Amy Hartsock, public information officer for IDEM. Because the materials disposed at the dump would not have generated gases, she said, the site isn't monitored for air pollutants - a more likely contributor to lung cancer than water contamination.

“I don't know that there's ever been any evidence that landfills cause lung cancer,” said Dr. Deborah McMahan, Allen County health commissioner.

Answers aren't always easy to come by when it comes to cancer. Many factors can contribute. Romines' doctor, Thomas Bond, suspects a lifetime of smoking is largely to blame for Romines' malady, although Bond thinks exposure to dust, vapor and the like at work could have played a role as well.

Bond, a physician with Parkview Medical Group in New Haven, sees some patients with pneumonitis - or inflammation of lung tissue, such as pneumonia - and bronchitis who worked in auto body businesses and other industrial jobs.

Responding to Journal Gazette questions, Romines' former employer, Karl Schmidt Unisia Inc., or KUS, said it is “committed to reducing potential risks to the environment, health and safety of its associates and the community. This goal is achieved through safe workplace practices, prevention of pollution, compliance with workplace laws and regulations, and continual improvement through training, auditing and testing.”

Based in Wisconsin, KUS has owned the Fort Wayne plant since 1999 and has been subject to various air-quality checks during that time. Each check showed air quality at the plant was within Occupational Safety and Health Administration regulatory limits, the company said. IDEM also audits the facility, and no issues have arisen from the audits.

In March, KUS was named as a charter member of Indiana's Environmental Stewardship Program. To be accepted into the program, a company must demonstrate exemplary environmental compliance, environmental management systems and plans for continuous environmental improvement.

If chemical contaminants were to blame for higher cancer rates in 46803, then other cancer rates would most likely be higher as well, Bond said. Analyzing cancer rates in the ZIP code, state epidemiologist Bob Teclaw found that in some cases, while other types of cancer were higher or lower than average, only rates of respiratory cancer - almost all lung cancer - were markedly higher than expected.

But the state health department wasn't able to determine what caused the higher rate of lung cancer. Many factors can contribute to lung cancer, including smoking and secondhand smoke, exposure to radon or asbestos, air pollution from automobiles and factories, and occupational exposure ranging from arsenic to chromium.

But smoking is far and away the No. 1 cause of lung cancer.

“It is important to remember that most lung cancers are caused by smoking and that it is the most likely explanation in the absence of other evidence,” said Ken Severson, a spokesman for the state health department.

Nationwide, smoking accounts for 87 percent of lung cancer deaths. The second-leading cause is radon, a colorless, odorless gas that occurs naturally in soil and rock, that accounts for 10 percent to 14 percent of cases, according to the American Lung Association.

The EPA assigns counties a color-coded rating for radon potential in homes based on indoor radon measurements, geology, aerial radioactivity, soil permeability and foundation type. Allen County is in a red zone, meaning it has the highest potential for elevated radon levels. It shares this rating with all other counties in northeast and central Indiana, along with some in the south-central part of the state.

A spokesman for the Fort Wayne-Allen County Department of Health didn't know of a more specific geographic breakdown of radon risk. Nor were health officials aware of a raised radon rate in the 46803 ZIP code that might account for a higher level of lung cancer cases.

A Journal Gazette review of environmental records in 46803 for the past 25 years also failed to produce any major compliance breaches by companies in the ZIP code that might be tied to a higher rate of lung cancer. The review looked at IDEM enforcement actions against companies during that period. IDEM personnel assisted in the search.

Although some compliance actions have been taken, there's nothing to point to any environmental issue related to an increased rate of respiratory cancer in the area, IDEM's Hartsock said. In addition to corporate oversight, the agency monitors hazardous air pollutants in the area.

“We are not seeing any elevated levels (of air pollutants) that would point to a problem from a facility or business operating in the Fort Wayne area,” Hartsock said.

Without an alternative explanation, health care providers are led down a familiar path, trailing plumes of smoke emanating not from factories, but people.

Hard to quit

Kathy Romines still smokes despite her husband's travails. The 52-year-old first lit up when she was a teen, the product of a smoking family, like Ray. These days, she smokes outside - or in the garage during the cold months - away from her husband.

“I thought about quitting. I don't know. I want to, but it's so darn hard,” she said. It doesn't help that her insurance won't pay for Chantix, a smoking-cessation medication that costs more than $100 a month.

And she now has another reason to lean on the habit. It takes the edge off dealing with her husband's cancer.

“Nervewise, I guess it helps,” she said.

The irony is not lost on her.

Kathy Romines considers smoking a contributor to cancer, but she's quick to add that there are other factors. “Nowadays there's just so much that can contribute to cancer.”

That rationale seems to dilute any remaining resolve she might have to quit. And it frustrates physicians trying to reinforce behavioral changes among patients who smoke.

It's hard for people to admit that they may be doing something that's killing them, McMahan said. She thinks smokers should concentrate more on kicking the habit and less on incidental exposures to other cancer-causing agents.

“How are you more likely to get third-degree burns, setting yourself on fire or standing 10 feet away from a campfire?” McMahan asked rhetorically. According to the World Health Organization, half of all regular smokers are killed by the habit.

Like other health care providers, McMahan doesn't rule out the possibility other factors could be responsible for the high rate of lung cancer in 46803. But she thinks a “dramatic” correlation between poverty and lung cancer rates in city ZIP codes points to smoking as the most likely cause.

The three ZIP codes with the highest poverty and lowest education rates in Fort Wayne - 46803, 46802 and 46806 - have the three highest lung cancer rates, in that order. Another ZIP code, 46808, which has a lung cancer rate nearly identical to ZIP code 46806, has the city's sixth-highest poverty rate and fourth-lowest high school graduation rate.

The state health department used information from a state cancer registry to compute cancer rates and census data to make age adjustments so meaningful comparisons could be made between ZIP codes with more older or younger residents. The department said that rates for ZIP codes with a smaller number of cases were less reliable than those with more cases; the four ZIP codes with the highest rates had more than 100 cases each compared with the lowest number of cases for any ZIP code: 22 in 46814.

The lung cancer rate for 46803 is about 136 cases per 100,000 people, based on cases between 1995 and 2005.

According to 2000 census data, nearly 31 percent of individuals residing in the ZIP code live below poverty level. Median household income in 1999 was $23,974, the lowest in Fort Wayne and far below the state median income of $41,567.

Despite the rising cost of cigarettes - a pack usually costs more than $3 - limited income and smoking often go hand-in-hand.

Karla Sneegas blames tobacco companies for targeting low-income populations in their marketing efforts, a charge that company representatives deny. Another factor is access to health care, said Sneegas, executive director of Indiana Tobacco Prevention and Cessation.

Poor people are more likely to lack health insurance and therefore less likely to go to a doctor. Those who are told by a doctor to quit smoking are 2 1/2  times more likely to kick the habit, but that's not a message many low-income smokers are getting, Sneegas said.

Low-income smokers who want to quit also have less access to cessation programs and are less likely to get benefits at work that would help them pay for such programs, she said.

Data from a 2006 Allen County study sponsored by the health department and several other local agencies suggest the smoking rate for low-income residents living in the 46803 ZIP code is higher than for low-income residents elsewhere in the county. Only a small group was surveyed, leaving more room for error. But anecdotal evidence from health care providers serving patients from the ZIP code and other nearby impoverished areas seems to support the assertion.

Nationwide, those making less than $15,000 smoke at twice the rate of those making $50,000 or more, according to the latest data from the Behavioral Risk Factor Surveillance System, a system established by the Centers for Disease Control and Prevention.

The 2006 statistics show a significant correlation with education as well.

Of those in Indiana who don't graduate from high school, 44.5 percent smoke, compared with 10.5 percent of those who graduate from college. That puts 46803 in the bull's-eye again because its graduation rates are the lowest in the city.

Double duty

People with cancer often work two jobs in respect to their disease: fighting the cancer - as Ray Romines has done with surgery and chemotherapy - and putting on a strong face for the world. Double duty can get tiresome, but Romines perseveres.

The rawness of his experience - exposed in weighty pauses when he talks about cancer - is interrupted by his wry sense of humor.

When a photographer met with Romines for this story, he made playful jabs at her throughout the shoot. He joked about his desire to become an investigative reporter at The Journal Gazette - he asked whether she could put in a good word for him - and told her the camera she was using looked professional.

His wife said that's just how he is.

The couple have been together 26 years, married for 18. It's hard for Kathy Romines to imagine life without her husband. She wonders how she would manage in his absence.

“You just think about it all the time. … It just makes me worry.”

Ray's hopeful he'll outlive his initial five-year prognosis despite those who have gone before him. His brother, Clyde, died in 1996 after cancer that started in his lungs advanced to his brain. His death still weighs heavily on Romines' mind.

But a few bright spots dot Romines' own battle with cancer.

Doctors and nurses have gone out of their way for him; he's gotten non-medical support from Cancer Services of Northeast Indiana; former co-workers even took up a collection to buy him groceries.

Knowing they care is a real morale booster, he said.

His last doctor's visit, in October, went well. His X-rays and blood tests revealed no additional problems, and he weighed a healthy 190 pounds, having regained the weight he lost to chemotherapy.

His next checkup is in February.

He's hoping for more good news. He heard recently about two people who lived longer than 12 years after their lung cancer diagnosis.

“I'm going to try,” he said, “to be the third.”

mschroeder@jg.net