MAXWELL, Iowa — Eight days from Election Day, Rob Sand is surrounded by knee-high grasses, surveying a wetlands nature preserve. This brief hike, in the waning hours of his hotly contested gubernatorial campaign, is tied to the issue roiling races up and down the ballot here: the cancer crisis.

Expanding the state’s wetlands is one part of the Democratic candidate’s plan to address the skyrocketing rates of cancer in Iowa, which ranks second-highest for new cancer diagnoses. Wetlands can improve water quality, which has been identified as one of several factors contributing to Iowa’s crisis. Sand’s Republican opponent, Zach Lahn, also lists wetlands expansion in his own cancer plan.

“I’m glad that we have two candidates that are willing to talk about funding” environmental projects focused on improving water quality, Sand told reporters Monday. “It’s a huge issue in this race that a lot of people find incredibly motivating.”But who voters ultimately blame for this crisis will be a core factor for whether Democrats are able to flip the state that backed President Donald Trump by successively larger percentages starting in 2016. Iowa Democrats believe there’s an opening for Sand and state Rep. Josh Turek, who is running for Senate, in this red state.

Democrats say it’s more than just cancer that could give them an edge here, pointing to deepening frustration over the Iran war, high gas prices and a chaotic tariff trade regime. As evidence of the stiff headwinds, the Congressional Leadership Fund — the flagship GOP super PAC — cut off its spending on behalf of Iowa Rep. Mariannette Miller-Meeks by mid-October. Republicans privately acknowledge that opening for statewide races, too.

“Everyone knows someone with cancer,” a national Republican consultant said of the situation in Iowa. They, like others who spoke to The Washington Sun, were granted anonymity to discuss the issue candidly. “These voters are saying, ‘Holy crap, this is a big problem, and Republicans have been in charge for over a decade,’ so there’s no other place to point finger.”

One Iowa Republican strategist called cancer “a liability for Republicans” and said it’s “a liability because of their past actions in the legislature.”It’s dragging down the entire ticket, the strategist acknowledged, while the party also is “suffering from an enthusiasm gap this whole cycle.”But the cancer crisis — and who to blame, and what to do about it — moved to the fore of debates, TV ads and campaign events this cycle in Iowa, a once-unthinkable reality given the state’s dependence on its agriculture industry. Cancer and water quality regularly rank among the top three issues for voters across the state, according to private polling of state legislative races shared with The Washington Sun.

More than $20 million has been spent by both parties airing ads referring to cancer specifically, according to AdImpact, the ad-tracking firm. In 2022, less than $200,000 was spent on ads that mentioned cancer.

Lahn, a businessman and farmer, put cancer at the center of his insurgent Republican primary campaign for governor this spring, becoming the face of the state’s “Make America Healthy Again” movement. As a first-time candidate, he beat the Trump-endorsed Republican, Rep. Randy Feenstra, in the primary. He did it all while blaming Big Ag and chemical companies for their role in the state’s rising cancer rates. That’s put him at odds with some of the traditional, GOP-aligned forces in the state.

“They all talk about it as a problem, but no one’s talking about the real issue, which is farming, so Lahn is an anomaly when it comes to a Republican actually really talking about it,” said state Rep. Jennifer Konfrst, a Democrat. “It’s hanging right there, but no one’s going to grab it because no one wants to piss off the farmers.”The gubernatorial candidates are trading shots over their connections to the cancer crisis in TV ads blanketing the state’s airwaves. Lahn accuses Sand’s “biggest donor” of getting “caught polluting your drinking water” while “Iowa cancer rates” are rising.

And Sand, in his own ads, attacks Lahn for supporting “budget cuts that slashed cancer research funding” and backing “a plan that would bankrupt rural hospitals.”But pro-Sand groups are outspending pro-Lahn efforts in TV ads, $38 million to $32 million, according to AdImpact.

Iowa state Sen. Molly Donahue, a Democrat who attended Sand’s canvass launch in Cedar Rapids last weekend, said voters are “absolutely” connecting the cancer crisis to who they vote for. But she isolated those who might flip to voting for a Democrat as the “moderate Republicans who absolutely agree” on who to blame. “We’re never going to convince the MAGA crowd,” she added. “I mean, there are a few who have flipped,” she said, “a few, but not many.”

In a statement, a Lahn campaign spokesman said that “career politicians like Rob Sand have had plenty of chances to tackle the cancer crisis,” but “they’ve failed because they don’t do hard things. Zach is an outsider who has never run for office before. He’ll stand up to the special interests with fresh, new ideas that will make Iowa the best place to live.”Sand, the state’s auditor, is the lone elected Democrat to survive the state’s red-leaning realignment over the past decade.

He’s raised more than double the cash Lahn has brought in, and national Democrats believe he’s one of the best-positioned candidates to flip a governor’s mansion. He has campaigned on “a crisis of costs, corruption and cancer,” while trying to shake free of the national Democratic Party label.

He’s also zeroed in on Lahn’s residency in Iowa: Public voting records show that Lahn voted in Kansas in 2018, 2020 and 2022, before registering to vote in Iowa in 2024.

“At the end of the day, people can trust me because they’ve seen my actions across the state of Iowa over time, and know that what I’m saying is stuff that I’ve actually — they can trust my actions that speak louder than words,” Sand said Monday.

Like Sand, Turek is also leaning into the cancer crisis in the final stretch of the campaign. In an interview with The Sun, he recounted how his sister, who lives in Council Bluffs, was diagnosed with Stage 2 breast cancer “nearly the day” he launched his Senate campaign. She hasn’t been able to get her insurance to cover a PET scan, Turek said, to see if her cancer spread because it was Stage 2, not 3 or 4, and they “basically said, ‘Sorry, you don’t have enough cancer.’”

“I think more and more people are paying attention to who actually cares about the health care crisis and the cancer crisis and the water quality crisis, and who is legitimately going to address it,” he said. Turek’s sister now appears in an ad running in the closing days of the campaign.

His opponent in the Senate race, Rep. Ashley Hinson, considered a star recruit by Republicans, has also advocated for more funding into cancer research. In a statement, National Republican Senatorial Committee spokeswoman Samantha Cantrell said that Hinson “wants to get Iowa’s cancer rates down quickly,” citing her recent bipartisan legislation to expand access to cancer screenings.

“Ashley will work with anyone to lower healthcare costs and get Iowa’s cancer rates under control,” Cantrell added.

Scott Kaas, a self-described “conservative Republican” who has “never voted for a Democrat in my life,” appeared in a digital ad on behalf of Turek, an endorsement based on their work to pass a bill funding pediatric cancer research. Kaas’ now 4-year-old daughter, Devyn, was diagnosed with bone marrow cancer at 7 months old and he started advocating on behalf of pediatric cancer patients soon after. She’s now in remission, he said.

But Kaas isn’t sure whether Turek’s work on cancer funding will persuade voters to do what he’s doing and cross party lines.

“Not many that I’ve spoken to,” Kaas said. “Honestly, they’re either a Republican or a Democrat, and that’s just the way they’re going to vote.”