Rural counties fall behind as U.S. cancer deaths decline

U.S. cancer death rates have fallen sharply since the early 1990s, but a county-level study found those gains have not reached many rural communities. Research by Mississippi State University sociologist Arthur Cosby and colleagues, published in the British Journal of Cancer, found that 458 rural counties recorded rising cancer mortality even as the national rate improved.

According to the American Cancer Society data cited by Cosby, cancer deaths in the U.S. peaked in 1991 at 215 deaths per 100,000 people, when cancer accounted for about one in four deaths. The rate then fell 34% between 1991 and 2022, a change associated with an estimated 4.5 million fewer cancer deaths.

Cosby’s team examined cancer death rates in nearly 3,000 U.S. counties from 1981 through 2019. The researchers found that national averages masked wide differences by geography and income, with the strongest improvements clustered in large, affluent metropolitan counties.

Urban counties saw the biggest gains

According to the study, major coastal metro areas on the Atlantic and Pacific coasts had some of the steepest drops in cancer mortality. The corridor from Boston to Washington, D.C., showed large declines, including drops of more than 40% in Manhattan, Queens, the Bronx and Brooklyn from 1991 to 2019.

Manhattan had a 47% decline in cancer deaths over that period, the study found. In the San Francisco Bay Area, Cosby’s team reported declines of 47% in Marin County, 44% in San Mateo County and 40% in San Francisco County.

Rural and small-town counties started from a different position, according to the researchers. Before 1991, rural and urban areas generally had comparable cancer death rates, but after the national rate began to fall, metropolitan counties improved much faster.

The study found slower declines across several rural states, including 20% in Mississippi, 23% in Arkansas, 24% in West Virginia and 29% in Montana. Cosby’s team also identified 458 rural counties where cancer mortality increased rather than decreased.

Income tracked closely with survival gains

The researchers also found a strong link between county income and cancer mortality improvement. In 1991, counties with high and low median family incomes showed little separation in cancer death rates, according to the study.

By 2019, the researchers found, the 10% of Americans living in counties with the highest median incomes had improvements in cancer mortality about seven times greater than the 10% living in counties with the lowest median incomes. Cosby’s team said the pattern showed that poorer counties had the least progress against cancer deaths.

The American Cancer Society and the Centers for Disease Control and Prevention have linked the national decline in cancer mortality to prevention, screening and treatment, according to Cosby. But the study said access to cancer services and adoption of preventive policies vary widely by county and state.

Tobacco policy is one example cited by the researchers. Lung cancer remains the leading cause of cancer death and has had the strongest mortality decline, and Cosby’s team pointed to smoking cessation programs, warning labels, tobacco taxes, age restrictions and smoke-free rules as factors in that progress.

New York City’s tobacco-control efforts were reflected in Manhattan’s lung cancer data, according to the study: the borough had 60% fewer lung cancer deaths in 2019 than in 1991. Rural areas, by contrast, often have higher smoking rates, more exposure to tobacco smoke at home, fewer smoke-free laws and less backing for tobacco-control policies, the researchers said.

Cosby’s team concluded that the U.S. has made major progress in cancer treatment and prevention while distributing those gains unevenly. The researchers said rural-focused screening and tobacco-control programs, along with better access to advanced treatment in rural and low-income areas, could help narrow the gap.

This story draws on original reporting from Fortune.