Between 1991 and 2022 the U.S. cancer death rate dropped 34%, which works out to about 4.5 million lives not lost. Yet in around 458 rural counties, cancer mortality actually rose. Same country, same decades, opposite direction.
The picture comes from Arthur Cosby, a professor emeritus at Mississippi State University’s Social Science Research Center, and colleagues at Oak Ridge National Laboratory. Their paper in the British Journal of Cancer tracks cancer deaths from 1981 to 2019 in nearly 3,000 counties. The raw material was CDC death certificates, covering over 23 million cancer deaths.
Where the gains landed
For decades before 1991 cancer deaths kept climbing, topping out at 215 for every 100,000 people. Rural and urban America looked much alike then. Once the national rate began to fall, the two pulled apart.
Walk the coasts and the numbers are striking. The Boston to Washington, D.C. belt saw deaths fall steeply. The four biggest boroughs of New York City each saw cancer death rates fall by more than 40% from 1991 to 2019, and Manhattan, the wealthiest, improved most, at 47% fewer deaths. Around San Francisco, deaths in Marin County fell 47%, in San Mateo County 44% and in San Francisco County 40%, all well beyond the national figure.
The interior tells another story. Non-metropolitan areas improved far less: 20% in Mississippi, 23% in Arkansas, 24% in West Virginia and 29% in Montana. “Place can make a huge difference in health outcomes, and this was certainly true for county cancer mortality,” Cosby said. “The geographic differences were stark.” The rural and urban gap was small to begin with and widened only as national rates dropped.
Money and tobacco
Income tracks the divide. When deaths peaked in 1991, there was little difference between the highest- and lowest-income counties. By 2019, the 10% of Americans living in the richest counties had gained about 7 times as much in lower mortality as the 10% in the poorest.
Cosby points to tobacco control as one driver. In Manhattan, after aggressive smoking rules, the lung cancer rate went from 49 per 100,000 in 1991 to 19.6 in 2019, a 60% reduction. Rural communities, the research notes, often have higher smoking rates, more tobacco smoke in the home, fewer smoke-free laws and weaker support for tobacco control.
“The dramatic reduction in cancer deaths occurs so unevenly across America,” Cosby said, “and there are many Americans who are not sharing this important improvement in the nation’s health.” His own prescription is practical: tobacco policies and screening methods designed for rural settings, and wider access to advanced treatment in rural and poor areas.
Sources
- SSRC researchers at MSU study shifts in cancer mortality (Mississippi State University)
- Rural areas lag behind in cancer treatment and prevention (Arthur Cosby, The Conversation, via Medical Xpress)
