Country People Are More Likely to Die from Cancer Than City People

Where you live affects your risk for both developing and surviving cancer. Regions with high death rates are often called high cancer burden areas. For the past 20 years, for all cancers combined and for several of the most common types of cancer the cancer burden areas have been higher in the country than in city. But there’s been less research about what happened before then. Understanding the factors that may lead to these geographical disparities in cancer burden requires examining a longer trend. Such research may also help improve public policies.

That’s why Senior Scientific Director of Cancer Disparity Research, Farhad Islami, MD, PhD, and other American Cancer Society (ACS) researchers, examined 55 years (1969 to 2023), almost 28 million records, from the National Center for Health Statistics. They evaluated death rates for: 

• All types of cancer combined
  
  
• 3 of the leading causes of death from cancer for men: prostate, colorectal, and lung
  
  
• 3 of the leading causes of death from cancer for women: female breast, colorectal, and lung

The team published their findings In a Brief Communication in the Journal of the National Cancer Institute (JNCI), about ways to decrease the differences in cancer death rates between rural and urban areas. They found that in the late 1960s, metropolitan (urban) areas had the highest burden of cancer, but the trend shifted to rural areas having the highest burden by the early 2020s.

In 1969 to 1971, large urban areas had a higher cancer burden than rural areas. 

Large urban areas with at least 1 million people had the highest overall cancer death rate for both males and females: 

• 265 males died from cancer out of every 100,000 people who died

• 170 females died from cancer out of every 100,000 people who died 

The areas with the lowest cancer burden for both males and females were rural (nonmetropolitan) areas with the smallest urban population of less than 5,000:

• 214 males died from cancer out of every 100,000 people who died 

• 147 females died from cancer out of every 100,000 people who died

In 2021 to 2023, the reverse was true: rural areas had a higher burden of cancer than large urban areas. 

Large urban areas with at least 1 million people had the lowest overall cancer death rate for both males and females: 

• 157 males died from cancer out of every 100,000 people who died

• 119 females died from cancer out of every 100,000 people who died

The areas with the highest cancer burden for both males and females were rural areas with the smallest urban population of less than 5,000:

• 198 males died from cancer out of every 100,000 people who died 

• 144 females died from cancer out of every 100,000 people who died

Top 3 cancers in men and women had the same trends in death rates for urban and rural areas. 

The trend for cancer burden for female breast cancer, colorectal, and lung followed the same kind of geographic shifts in the same time periods—higher death rates in large urban areas from 1969 to 1971 and higher death rates in rural areas from 2021 to 2023.  

The reversal in mortality was largest for lung cancer:

• In 1969 to 1971, lung cancer was lower in rural areas than large urban ones: 26% lower for males 35% lower for females.

• In 2021 to 2023, lung cancer was higher in rural areas than large urban ones:  55% higher for males and 47% higher for females.

What Caused the Shift?

The crossover happened in the 1990s for males and in the early 2000s for females, and after that, the mortality gap between rural and urban areas continued to widen. 

The authors say the “likely major contributors” to the trend of the cancer burden shifting from large urban areas to rural ones, included:

• Growing inequalities in social and environmental conditions (known as the social determinants of health) influence people's exposure to risk factors, such as food security, availability of transportation, employment, income and wealth, and health insurance coverage. Over the years, the geographic distribution of the social determinants of health changed. For instance, in the past 20 years, rural areas:
  
  
  • Experienced more job loss or slower job growth, lower wages and income, and lack of economic diversification than large urban areas.
    
    
  • Had more people with incomes below the federal poverty level and without health insurance, which makes people in rural areas more likely to have financial barriers for getting cancer treatments, which may cause them to delay or skip recommended care..
     
• Inequalities in access to and affordability of preventive and other health care services. For instance, in the past 20 years, rural areas:
  
  
  • Had less widespread use of improved diagnostic technologies and advances in cancer treatment, which increased the gap between the early detection and treatment of cancer between rural and large urban areas.
    
    
  • Had more limited access to oncology specialists and comprehensive cancer care providers than large urban areas, which increased the gap between worse cancer outcomes between rural and large urban areas.

Closing these gaps, the researchers say, "requires more intersectoral collaboration, targeted funding, and effective policies to improve access to care across the cancer continuum.

Other ACS Surveillance, Prevention, & Health Services (SPHeRe) researchers who contributed to this study were Hyuna Sung, PhD, Elizabeth Schafer, MPH, Rebecca Siegel, MPH, and Ahmedin Jemal, DVM, PhD. They were helped by a researcher in the Department of Health Management and Policy within the University of Iowa.

People in Rural or Most Deprived Areas Are Less Likely to Visit Health Care Providers and More Likely to Have Fair or Poor Health 

After treatment ends, cancer survivors’ routine follow-up visits are key to finding any recurring cancer early, getting help for ongoing symptoms from the cancer or side effects from treatment, and getting feedback and encouragement on following a healthy lifestyle to help prevent the development of another type of cancer.

In the United States, most cancer survivors have follow-up visits with oncologists for the first 5 years after treatment. They may see primary care physicians and other non-oncology specialists for the management of chronic conditions and oversight of preventive care. 

It’s well known that people who live in rural or economically deprived areas often have less access to health care. Yet there is limited information about how often cancer survivors living in these areas receive follow-up care.

The ACS SPHeRe study, published in Med and led by Hyunjung Lee, PhD, is one of the first studies to examine disparities in health and health care utilization based on residency in a rural or deprived area. The researchers evaluated the link between a cancer survivor's health or health care based on where they lived in the US using data from the All of Us Research Program. They analyzed data from about 26,000 cancer survivors.

They found that cancer survivors who lived in rural or economically deprived areas were less likely to visit health care professionals and more likely to have a fair or poor health status. Specifically, compared to cancer survivors living in the least economically deprived areas, survivors in the most deprived areas were less likely to have had visits with nurse practitioners, physician assistants, or mental health professionals. 

The research authors advised, “Given the shortage of oncologists or primary care providers in rural or deprived areas, collaborative survivorship care involving oncologists and other health care professionals, including primary care physicians, NPs and PAs, and mental health professionals is critical to improve cancer survivorship care.”

Other ACS SPHeRe researchers who contributed to this study were Dongjun Lee, MS, Daniel Wiese, PhD, Ahmedin Jemal, DVM, PhD, and Farhad Islami, MD, PhD.