Rural-Urban Breast Cancer Mortality Gap Projected to Widen in Next Decade

Breast cancer mortality rates are projected to diverge further between rural and urban populations in the United States over the next decade, with socioeconomic conditions, later-stage diagnosis, and differences in treatment receipt contributing to the disparity.¹

An analysis presented at the 19^th American Association for Cancer Research (AACR) Conference on the Science of Cancer Health Disparities highlight that by 2035, the age-adjusted breast cancer mortality rate among rural populations is projected to be approximately 13% higher than that among urban populations. The projected difference represents approximately 38 additional breast cancer deaths per 1 million women in rural areas compared with urban areas.

“Although breast cancer mortality has declined overall in the United States, our findings underscore that this progress has not been shared equally between rural and urban communities,” Nickolas Stabellini, MD, PhD, of Case Western Reserve University and University Hospitals Seidman Cancer Center, and study presenting author stated in a news release. “The reduction in breast cancer mortality has occurred more slowly in rural communities, contributing to persistent rural-urban disparities. Our study provides updated information on these trends and goes a step further by examining the patient and community factors that may help explain the difference.”

Mortality Trends

To evaluate changes in breast cancer mortality over time, investigators analyzed data from the Centers for Disease Control and Prevention’s WONDER database covering 1999 through 2020. Among 1,156,445 breast cancer deaths recorded during this period, 189,586 occurred among rural patients and 966,859 among urban patients.

Age-adjusted breast cancer mortality declined in both populations between 1999 and 2020, but the rate of decline was slower in rural areas. By 2005, mortality among rural patients had surpassed that among urban patients. After fluctuating in subsequent years, rural mortality remained consistently higher beginning in 2013.

By 2020, the age-adjusted mortality rate was 32.51 deaths per 100,000 in rural populations compared with 30.48 deaths per 100,000 in urban populations, a difference of approximately 7%. The absolute gap, approximately 2 deaths per 100,000 women in 2020, is projected to increase to approximately 3.8 deaths per 100,000 by 2035 if current trends continue.

Findings: Factors Associated With Excess Mortality

To examine potential contributors to the disparity, researchers analyzed National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) data from 688,165 patients diagnosed with breast cancer between 2000 and 2020; 10.2% lived in rural areas.

Before adjustment, rural patients had a 21% higher risk of breast cancer-related death than urban patients. After accounting for age, race, ethnicity, tumor stage, molecular subtype, and receipt of chemotherapy and radiotherapy, the excess risk decreased to 3%.

County-level income was the largest identified contributor, accounting for 45.3% of excess deaths among rural patients. Advanced stage at diagnosis accounted for 24.9%, omission of radiotherapy for 11.4%, and omission of chemotherapy for 7.9%. Race and ethnicity did not contribute to the disparity in this analysis.

County-level income accounted for nearly twice the proportion of excess deaths attributed to advanced-stage diagnosis, underscoring the importance of socioeconomic conditions in understanding the mortality gap. These findings suggest that disparities in breast cancer outcomes may reflect not only differences in cancer detection and treatment but also the financial circumstances of the communities in which patients live.

Limitations and Implications for Cancer Care

Given the observational nature of the study, while the findings do not establish a causal relationship between the investigated factors and mortality, the results point to financial barriers and access to care as potential targets for reducing rural-urban disparities. Rural patients may encounter barriers to screening and timely diagnostic evaluation, although geographic disparities in breast cancer diagnosis can vary by population and location. Previous research has linked differences in late-stage diagnosis to socioeconomic conditions and spatial access to health care.²

Stabellini emphasized that reducing the disparity will likely require interventions at multiple points along the cancer care continuum, rather than a single intervention. “Rural patients may have greater difficulty obtaining screening, accessing timely diagnostic testing, seeing specialists, or traveling repeatedly for treatment,” he said. “These challenges may contribute to later-stage diagnosis, differences in treatment receipt, and, ultimately, differences in breast cancer outcomes.”

The findings therefore support efforts to address financial barriers, improve timely diagnosis, and reduce differences in access to indicated treatment as part of broader strategies to improve breast cancer outcomes in rural communities.

REFERENCES

1. Disparities in Breast Cancer Mortality Between Rural and Urban Patients Projected to Widen by 2035. News release. American Association for Cancer Research. October 18, 2026. Accessed October 20, 2026. https://tinyurl.com/344h4dkc

2. McLafferty S, Wang F, Luo L, Butler J. Rural - urban inequalities in late-stage breast cancer: spatial and social dimensions of risk and access. Environ Plann B Plann Des. 2011;38(4):726-740. doi:10.1068/b36145