Where a person lives in the United States increasingly shapes their chances of developing and surviving cancer. A new large nationwide study by researchers at the American Cancer Society (ACS) reports a long-term shift in the high cancer burden from urban to rural areas in the United States. The findings show that the mortality gap between those living in urban and rural areas continues to widen. The study was published by Islami et al in the Journal of the National Cancer Institute.
Higher cancer mortality rates for rural residents in the United States are largely driven by limited access to care, lower screening rates, higher poverty, higher prevalence of smoking, and several other factors that cause cancer. Understanding long-term trends in cancer mortality across rural and urban areas can provide additional insight into the factors contributing to rural-urban disparities and inform public policy.
“Differences in cancer risk factors, and in access to early detection and treatment, are likely major contributors to this shift in the high cancer burden from urban to rural areas,” said lead study author Farhad Islami, MD, PhD, Senior Scientific Director, Cancer Disparity Research at the ACS. “Unfortunately, these trends largely reflect growing inequalities in social determinants of health.”
Study Methods and Results
For the study, researchers analyzed data from 27,710,318 cancer deaths. They examined trends in cancer mortality rates overall and in three leading causes of cancer death in each sex (lung, colorectal, female breast, and prostate) by the urbanicity of county of residence in the United States from 1969 through 2023, using records from the National Center for Health Statistics spanning 55 years.
In 1969–1971, large metropolitan areas had the highest overall cancer mortality, followed by small- to medium-sized metropolitan areas, and nonmetropolitan areas with an urban population of 5000 or more; the lowest rate was in nonmetropolitan areas with the smallest urban population of 5,000 or less.
In 2021–2023, the mortality ranking was reversed: nonmetropolitan areas with the smallest urban population had the highest rates, while large metropolitan areas had the lowest rates. The crossover occurred in the 1990s for males and in the early 2000s for females, after which the rural-urban mortality gap continued to widen.
A similar pattern was observed for lung, colorectal, and breast cancer mortality with variations in crossover years, with the largest reversal for lung cancer. Among males, for example, the lung cancer mortality rate in nonmetropolitan areas with an urban population of 5,000 or less was lower by 26% in 1969–1971 but higher by 55% in 2021–2023 compared with large metropolitan areas.
Prostate cancer mortality rates were comparable across categories of urbanicity in 1969–1971, but in 2021–2023, the rate was higher in other categories of urbanicity than in large metropolitan areas.
Other Recent Research
In other recent ACS research, disparities also persisted concerning rural living and cancer survivors. The study, led by Hyunjung Lee, PhD, and published last month in the journal MED, showed cancer survivors residing in rural or the most deprived areas had poorer health and were less likely to visit primary or specialty health-care providers compared with those living in urban areas or the least deprived areas.
“The findings underscore the importance of team-based survivorship care that includes oncologists, primary care clinicians, nurse practitioners, and mental health professionals, especially in communities facing provider shortages and in underserved areas,” Dr. Lee said. “Since each community may have different needs, resources, and collaborative partnerships, different solutions may be necessary, including the establishment of satellite clinics, the expansion of telehealth resources, the implementation of educational and workforce initiatives, and the training of nononcologists to deliver care.”
DISCLOSURE: For full disclosures of the study authors, visit academic.oup.com/jnci.
