Breast Cancer Death Gap Between Rural and Urban Women Could Widen by 2035

Breast cancer death rates have dropped for women across the United States over the past two decades. However, they have fallen more slowly in rural areas, and that gap is projected to grow over the next 10 years, according to research presented at the 19th AACR Conference on the Science of Cancer Health Disparities, held Oct. 18-21 in Atlanta.

By 2035, breast cancer death rates among rural women are projected to be about 13% higher than among urban women. That works out to roughly 38 additional deaths per 1 million women, Targeted Oncology reported.

“Patients living in rural areas face a particularly high risk of dying from the disease,” presenting author Dr. Nickolas Stabellini, a postdoctoral scholar at Case Western Reserve University and University Hospitals Seidman Cancer Center in Cleveland, said in a news release. “If we want to address this disparity and improve outcomes, we need to understand where the trends are heading.”

A gap that has grown since 2013

The researchers used the Centers for Disease Control and Prevention’s CDC WONDER database to track breast cancer deaths from 1999 to 2020. The database recorded more than 1.15 million breast cancer deaths in that period, including 189,586 among rural residents.

Rural death rates first passed urban rates in 2005 and have stayed higher every year since 2013. By 2020, rural women died of breast cancer at a rate of 32.51 per 100,000, compared with 30.48 per 100,000 for urban women. That is about 7% higher.

What is driving the difference

To understand why, the team looked at 688,165 patients diagnosed between 2000 and 2020 in the National Cancer Institute’s SEER database.

Before accounting for other factors, rural patients had a 21% higher risk of dying from breast cancer. After the researchers adjusted for age, race, ethnicity, stage at diagnosis, tumor subtype and whether patients received chemotherapy or radiation, the extra risk fell to 3%. That suggests most of the gap comes from factors that can be changed, not from where patients live in itself.

The largest share of excess rural deaths came from lower county-level income (45.3%), followed by advanced-stage disease at diagnosis (24.9%). Not receiving radiation accounted for 11.4% of excess deaths, and not receiving chemotherapy accounted for 7.9%. Race and ethnicity did not contribute to the rural-urban difference.

Stabellini pointed to barriers such as access to care, which he said “may contribute to later-stage diagnosis, differences in treatment receipt” for rural patients. “Identifying how these differences arise can help guide interventions aimed at reducing disparities,” he said.

Other studies find similar trends

The findings follow two American Cancer Society studies presented at the ASCO Quality Care Symposium in Boston earlier this month. In one, which included more than 2.8 million women, the excess risk of death for women in nonmetropolitan areas rose from 3.4% during 2010-2016 to 9.3% during 2017-2023, compared with women in large metro areas.

“Our findings raise concern that the benefits of those advances may not be reaching women in rural communities,” lead author Dr. Jingxuan Zhao of ACS said in a news release.

What this means for patients

The AACR study is observational, so it can show links but cannot prove cause and effect. Still, it points to areas where patients and caregivers can act: staying current on screening mammograms, asking about all recommended treatments, including radiation, and asking care teams about travel, lodging or financial assistance programs if distance or cost is a barrier.

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