Rural-Urban Patterns of Cancer

In the United States (U.S.), as of 2023, an estimated 62% of the counties in the U.S. are classified as rural (nonmetropolitan) [1], and 16% of the U.S. population live in rural areas [2].  Evidence shows that rural areas face significant disadvantages, including socioeconomic deprivation, limited access to quality healthcare, and higher risk factors for cancer compared to urban areas. Rural residents tend to be older, engage in more health-compromising behaviors (such as tobacco use), adhere less to preventive care, and are more often uninsured or reliant on Medicaid, which increases their risk for cancer and chronic diseases. These health patterns are further exacerbated by longer travel times to healthcare and shortages of primary care physicians, oncologists and other cancer care specialists [3].   

In 2024, an estimated 2 million people will be diagnosed with cancer in the United States and an estimated 611,720 people will die of cancer in the United States [4].

Overall, breast, lung and bronchus, prostate, and colorectal cancers are the most common cancers in both rural and urban areas in the U.S., accounting for the estimated 53% of all new cancer cases.

The most common causes of cancer deaths are lung and bronchus, colorectal, pancreatic, and breast cancers, responsible for an estimated 54% of all deaths from cancer [5].

Evidence suggests that some cancers are more common in rural areas while others are more common in urban areas [6-7]. Among the four most common cancers, lung and colorectal cancers occur more often in rural populations. The elevated incidence rates of lung cancer in rural areas are mostly attributed to higher rates of tobacco use [8], while the elevated incidence rates of colorectal cancer rates are for the most part attributed to obesity and lower adherence to screening [9-10].

Conversely, female breast and prostate cancer incidence rates are generally higher in urban areas, largely due to higher screening rates that lead to earlier diagnosis [7].

Death rates for the leading causes of cancer death – lung, colorectal, pancreatic, and breast cancers – are higher in rural areas. Patterns in death rates between rural and urban areas are larger for lung and colorectal cancer and comparably small for breast and pancreatic cancers.

Rural patterns in cancer mortality appear to be worsening, likely due to the effects of rurality on access to cancer prevention, diagnosis, and treatment services, as well as the higher prevalence of risk factors such as tobacco use and obesity in these areas [3].

Rural residents face challenges related to accessing healthcare services. Rural areas often have fewer primary and specialty care physicians as well as fewer home- and community-based service providers compared to urban areas [11]. Although an estimated 16%-of the U.S. population resides in rural areas, only 3% of medical oncologists practice in rural communities [12].

The map of Health Professional Shortage Areas (HPSA) reveals distinctly higher need for primary care health professionals in rural (nonmetropolitan) counties as compared to urban areas [13]. The Bureau of Health Workforce, Health Resources and Services Administration (HRSA) reports that 66.52% of primary medical HPSAs are rural, 28.92% are non-rural, and 3.93% are partially rural, with 0.63% having an unknown status [14].

While definitions of persistent poverty differ, typically geographic areas are considered in persistent poverty if they maintained poverty rate of 20% or higher for three decades. According to the U.S. Census Bureau, about 10.9% of the nation’s counties experienced 20% or higher poverty rate during the three decades period from 1980 to 2015-2019 [15]. These persistent poverty counties are disproportionately concentrated in the rural South, and are characterized by higher proportion of minority populations, lack of quality education, pervasive joblessness, discrimination, increased crime, limited access to medical services and healthy food, and other structural challenges [16].  

In addition to adverse social, economic, and structural conditions facing populations in persistent poverty areas, these areas have a higher prevalence of high-risk behaviors (e.g. smoking) and lower adherence to preventive care than urban areas, placing residents at greater risk of developing cancer [3]. Research suggests that overall cancer mortality is significantly higher in persistent poverty compared to nonpersistent poverty counties.

Furthermore, residents of persistent poverty counties remain at increased risk for death from lung and bronchus cancer, colorectal cancer, stomach cancer, and liver and intrahepatic bile duct cancer [17-18].

Populations living in rural communities have higher rates of high-risk behaviors, such as tobacco use, and poor diet, placing them at higher risk of cancer and other chronic diseases [3].

Rural communities continue to bear a disproportionate burden of health harms related to tobacco use. In 2021, the prevalence of any tobacco product use among adults in rural areas was 26.2%, compared to 17.5% in urban areas. Similarly, the prevalence of smokeless tobacco use was higher in rural areas, with 4.5% of rural adults using smokeless tobacco, compared to only 1.8% in urban areas [19,20]. This pattern highlights the ongoing public health challenges faced by rural populations in addressing tobacco-related health risks.

Compared with people of normal weight, those who are overweight or obese are at greater risk for many diseases, including diabetes, high blood pressure, cardiovascular disease, stroke, and many cancers [20].

Overall, obesity prevalence is significantly higher among adults living in rural counties (34.2%) than among those living in urban counties (28.7%) [22]. Research has documented that rural residents are more likely to be physically inactive and have unhealthy diets when compared to urban residents. Persistent poverty, food insecurity, lack of access to healthy food, and fewer recreational facilities that promote physical activity in rural areas are major contributors to increased risk for obesity in rural areas [23]. 

Rural-urban differences in access to and utilization of cancer screening services likely contribute to geographic patterns observed in cancer incidence and mortality. Studies have found that rural residents have generally lower rates of cancer screening and experience lower quality cancer care. Additional contributing factors include lower income levels, lack of insurance, less awareness of cancer risks and the benefits of screening, and distance to a screening facility.

American Cancer Society (ACS) reported that in 2021 the prevalence of being up to date with breast, colorectal, and cervical cancer screening was lower in nonmetropolitan areas than in large metropolitan areas [24]. Specifically, breast cancer screening rates for women aged 45 years and older were 63.9% in metropolitan areas and 61.1% in non-metropolitan areas. Colorectal cancer screening shows similar rural-urban patterns. In 2021, 59.7% of individuals aged 45 and older in large metropolitan areas were screened, compared to 59.0% in smaller metropolitan areas and 56.1% in rural areas. Cervical cancer screening also reflects these geographic patterns. In 2021, cervical cancer screening rates for females aged 25–65 years, were 75.8% in metropolitan areas with populations over 1 million and 71.8% in rural areas.

Rural communities experience elevated incidence and mortality of human papillomavirus (HPV)-associated cancers and correspondingly lower HPV vaccination rates. Data from the 2023 National Immunization Teen Data show that up-to-date HPV vaccination coverage for adolescents in rural areas is on an average 53%, compared to 64% in urban areas. This highlights the ongoing pattern between rural and urban communities in HPV vaccination coverage [25]. Some of the challenges to HPV vaccination in rural communities include lack of knowledge about the virus and vaccine, high monetary cost, challenges in transportation, distance, limited parental/peer support, cultural views, fatalistic beliefs, and the fact that the vaccine is not mandated and/or viewed like other vaccines [26].

Recently, the National Advisory Committee on Rural Health and Human Services issued policy recommendations to the Secretary underscoring the importance of greater funding support for the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the National Cancer Institute (NCI) to develop, implement, and evaluate a rural patient navigation program to enhance care coordination, particularly in tribal communities and persistent poverty counties [27].

To better understand and improve cancer control in rural communities across the continuum (prevention, screening, diagnosis, treatment, survivorship, end-of-life), NCI's Division of Cancer Control and Population Sciences undertook an in-depth analysis of its extramural research funded from 2011-2016 and found that only 3% of the division's portfolio focused on rural populations. These findings provided an impetus for NCI to increase its investment in rural cancer control research and initiate strong partnerships with other national health agencies in this domain [28].

In 2018 and 2019, NCI awarded supplemental funding to over 20 NCI-designated Cancer Centers to strengthen research capacity in rural remote areas and foster partnerships between the Cancer Centers and rural health facilities [29]. In 2020, through supplements, NCI funded R01 investigators to include geographically underserved and remote areas [30]. Moving forward, NCI will continue to engage national, state, and local research and practice communities for input and guidance on how best to move the field of rural cancer control forward [31].