Survival and mortality disparities for women with breast cancer are widening between rural and urban areas over time, according to findings from two American Cancer Society studies presented at the 2026 ASCO Quality Care Symposium (Abstracts 208 and 253).
The studies found that women from rural communities demonstrated worse survival outcomes from breast cancer than those from metropolitan areas.
“What stands out is not simply that women in rural communities experienced worse breast cancer survival, but that the gap widened over time,” said lead study author Jingxuan Zhao, PhD, MPH, Principal Scientist, Health Services Research, at the American Cancer Society. “At a time when breast cancer detection and treatment have improved substantially, our findings raise concern that the benefits of those advances may not be reaching women in rural communities.”
First Study: Survival Trends
The first study examined survival trends in women with breast cancer by residency. Using the National Cancer Database, researchers looked at data from 2,821,166 adult women with breast cancer newly diagnosed between 2004 and 2023. They compared survival after cancer diagnosis over time by residency and race, adjusting for sociodemographic characteristics.
Women in small metropolitan and nonmetropolitan areas, which included both micropolitan and rural areas, were more likely than those in large metropolitan areas to have inferior 5-year survival between 2004 and 2023. The differences also increased over the time period of the study.
Compared with women with breast cancer in large metropolitan areas, women in small metropolitan areas had a hazard ratio (HR) for 5-year survival difference of 1.054 for the years 2010 to 2016, which increased to 1.083 for 2017 to 2023 (P < .001). Similarly, for women in nonmetropolitan areas, the HR was 1.034 for 2010 to 2016 and 1.093 for 2017 to 2023 (P < .001).
When analyzing by race, the researchers found that non-Hispanic White women residing in small metropolitan areas experienced a 4.4% higher risk of death for 2010 to 2016 and 7.9% higher risk for 2017 to 2023 (P < .001); for non-Hispanic White women in nonmetropolitan areas, the respective risks were 0.9% and 8.1% higher (P < .001). Among non-Hispanic Black women residing in small metropolitan areas, risks of mortality were 3.2% higher for 2010 to 2016 and 7.9% higher for 2017 to 2023 (P < .001), and for non-Hispanic Black women in nonmetropolitan areas, the respective risks were 1.5% and 7.2% higher (P < .001).
“Women living in rural areas often face longer travel distances, fewer oncology specialists, and more limited access to screening, diagnosis, and treatment services,” Dr. Zhao noted. “Strengthening rural health-care infrastructure, reducing travel barriers, and improving access to cancer care could help ensure more women benefit from advances in breast cancer treatment.”
Second Study: Mortality Trends
The second study, led by Xuesong Han, PhD, explored the stage at diagnosis and mortality trends of cancers that can be detected early and looked at differences by residency. Looking at the North America Association of Central Cancer Registries' public research data set as well as the National Center for Health Statistics mortality data, the research team explored distant-stage incidence and all-stage mortality rates for 1995 to 2022. They focused on colorectal cancer, melanoma, and lung cancer in both men and women; breast and cervical cancers in women; and prostate cancer in men. They also explored differences by residency in absolute and relative terms, but excluded the year 2020 due to the COVID-19 pandemic.
Age-standardized distant-stage incidence rates increased for melanoma, female breast, and cervical cancers between 1995 and 2022 for patients in both urban and rural areas. Rates for prostate cancer increased in the more recent time period after declining significantly before 2011. Rates for colorectal cancer decreased continuously, and rates for lung cancer decreased since around 2010.
Mortality rates decreased continuously across all of the studied cancer types, except for lung cancer in women from rural areas, where the rate only began to decrease after 2008.
Distant-stage incidence rates increased more quickly in rural areas than urban areas, coupled with more slowly decreasing mortality rates, which contributing to a widening disparity by residency. The pattern continued across most cancer types that can be detected early, except for prostate cancer, where the difference between rural and urban areas was minimal across the study time periods.
For breast cancer specifically, mortality rates were lower in rural areas than in urban areas for the years 1995 to 1999, but then that trend reversed and mortality rates were higher by 2018 to 2023 in rural areas compared with urban areas.
“Your ZIP code shouldn’t determine your cancer outcome,” said Lisa A. Lacasse, President of the American Cancer Society Cancer Action Network, ACS’ advocacy affiliate. “The challenges patients living in rural areas face in accessing cancer preventive and treatment services must be addressed. We urge lawmakers to support policies that help improve access to comprehensive, affordable health insurance and require health plans to maintain strong networks, so that patients can access the health-care professionals and treatments they need, no matter where they live.”
DISCLOSURE: For full disclosures of the study authors, visit asco.org.
