Cervical Cancer Mortality Gap Widens Between Rural and Urban Areas

Cervical cancer is on the rise in the US, according to recent data,^1,2 but certain populations of patients in the country may be at a greater disadvantage for worsened outcomes: women who live in a rural location vs an urban setting and women of minoritized populations.

A new report published online today in JAMA Network Open explains how suboptimal screening and diagnostic and therapeutic care may be contributing to disparately magnified prevalence of and mortality from this cancer between rural- and urban-dwelling women in the US,³ which can have a 5-year 91% survival rate if caught and diagnosed at an early, localized stage compared with 19% from a late-stage diagnosis with distant metastasis.⁴

Using data on cervical cancer cases and mortality from 2001 through 2019 that they gathered from the National Program of Cancer Registries and Surveillance, Epidemiology, and End Results and the National Center for Health Statistics, respectively, researchers estimated 5-year mortality and annual rates for cervical cancer.³ They also used data from the Behavioral Risk Factor Surveillance System to adjust for survey-weighted smoothed hysterectomy prevalence. Rates were estimated per 100,000 women.

Results Overall

The study authors found 222,425 cases of cervical cancer in the US between 2001 and 2019, with a majority seen among non-Hispanic White women (59.9%) who lived in an urban county (84.3%). However, when corrected for hysterectomy, the incidence rate per 100,000 was 19% higher in a rural vs an urban county: 11.9 vs 10.0.

Additional differences became apparent after comparing 2 time periods:

• For rural counties, there was a 0.85% annual increase (95% CI, 0.08%-2.05%) in the incidence of cervical cancer between 2012 and 2019 after having decreased between 2001 and 2012
• For urban counties, the annual percentage change (APC) was –0.03 (95% CI, −0.89% to 2.00%) between 2013 and 2019, which the authors noted was a plateaued rate after decreasing from 2001 to 2013

The authors explain that these data illustrate an overall widening gap in rural and urban incidence from 2013 to 2019, with rate ratios (RRs) of 1.16 (95% CI, 1.10-1.22) and 1.25 (95% CI, 1.19-1.31), respectively.

Mortality was 1.42 (95% CI, 1.33-1.51) times higher in the rural vs the urban counties.

Results by Race and Ethnicity

When considering differences by race and ethnicity, the data show rural-dwelling women to be at a distinct disadvantage in cervical cancer incidence:

• Among urban Hispanic women for 2001 to 2012 and 2012 to 2019, the APCs were –4.20% (95% CI, –4.76% to –3.75%) and –0.34% (95% CI, –1.17% to 0.83%), respectively, while for rural Hispanic women, the APC was –2.72% (95% CI, –4.00% to –1.32%) between 2001 and 2019
• Among urban non-Hispanic Black women for 2001 to 2004 and 2004 to 2019, the APCs were –5.43% (95% CI, –8.99% to –2.72%) and –2.41% (95% CI, –2.83% to –0.62%), respectively, while for rural non-Hispanic Black women, the APCs were –3.23% (95% CI, –7.30% to –2.24%) and 9.07% (95% CI, –2.84% to 17.84%) for 2001 to 2017 and 2017 to 2019, respectively
• Among urban non-Hispanic White women for 2001 to 2003 and 2003 to 2019, the APCs were –4.95% (95% CI, –6.53% to –1.62%) and –0.40% (95% CI, –0.59% to –0.10%), respectively, while for rural non-Hispanic White women, the APCs were –1.60 (95% CI, –2.12% to –1.23%) and 1.05% (95% CI, 0.24%-2.33%) for 2001 to 2012 and 2012 to 2019, respectively

For 2005 to 2009, 2010 to 2014, and 2015 to 2019, the RRs also were elevated in rural vs urban locations, in most instances:

• 2005 to 2009:
  • Hispanic: 1.25 (95% CI, 1.03-1.52)
  • Non-Hispanic Black: 1.38 (95% CI, 1.15-1.66)
  • Non-Hispanic White: 1.41 (95% CI, 1.30-1.53)
• 2010 to 2014:
  • Hispanic: 0.97 (95% CI, 0.78-1.20)
  • Non-Hispanic Black: 1.43 (95% CI, 1.18-1.74)
  • Non-Hispanic White: 1.40 (95% CI, 1.29-1.51)
• 2015 to 2019:
  • Hispanic: 1.33 (95% CI, 1.12-1.58)
  • Non-Hispanic Black: 1.58 (95% CI, 1.32-1.90)
  • Non-Hispanic White: 1.54 (95% CI, 1.43-1.67)

Making Inroads With the HPV Vaccine

The investigators explain that if not addressed, the care barriers that are contributing to these outcomes disparities may only worsen, with potential exacerbations from lower human papillomavirus (HPV) vaccine uptake in rural areas.⁵ This is despite clear evidence that the HPV vaccine is presently preventing cancer in the US among women and men.^6,7

There is already policy-level evidence of cervical cancer disparities in the rural South among Black women living in the Mississippi Delta region. A report released in January, from the Southern Rural Black Women’s Initiative for Economic and Social Justice and Human Rights Watch, details the systemic shortcomings and lack of reproductive care that are likely to blame for a disproportionately higher rate of cervical cancer–related deaths among Black women vs White women.⁸ A principal factor involved in these disparate health outcomes is limited access to the HPV vaccine.

The overall message from the authors of the present report is that if preventive care, by way of HPV vaccination and screening, does not improve in and for rural US counties, “disparities are likely to magnify in future years.”³

References

1. Shahmoradi Z, Damgacioglu H, ClarkeMA, et al. Cervical cancer incidence among US women, 2001-2019. JAMA. 2022;328(22):2267-2269. doi:10.1001/jama.2022.17806

2. Amboree TL, Damgacioglu H, Sonawane K, Adsul P, Montealegre JR, Deshmukh AA. Recent trends in cervical cancer incidence, stage at diagnosis, and mortality according to county-level income in the United States, 2000-2019. Int J Cancer. 2024;154(9):1549-1555. doi:10.1002/ijc.34860

3. Amboree TL, Damgacioglu H, Chiao EY, et al. Rural-urban disparities in cervical cancer incidence and mortality among US women. JAMA Network Open. 2025;8(3):e2462634. doi:10.1001/jamanetworkopen.2024.62634

4. Survival rates for cervical cancer. American Cancer Society. Updated January 16, 2025. Accessed March 1, 2025. https://www.cancer.org/cancer/types/cervical-cancer/detection-diagnosis-staging/survival.html

5. Elam-Evans LD, Yankey D, Singleton JA, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years—United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(33):1109-1116. doi:10.15585/mmwr.mm6933a1

6. Johnson CK. HPV vaccines prevent cancer in men as well as women, new research suggests. AP News. May 23, 2024. Accessed March 2, 2025. https://apnews.com/article/hpv-vaccine-oral-cancer-prevention-males-749bf59c10d8a5a86c71c89c50eda0cb

7. Johnson CK. CDC report adds to evidence that HPV vaccine is preventing cervical cancer in US women. AP News. February 27, 2025. Accessed March 2, 2025. https://apnews.com/article/hpv-gardasil-vaccine-cervical-cancer-kennedy-32cdcf325d12cbc6610f01430d4ee82b

8. Shaw M. Health system policy failures drive cervical cancer disparities in rural South. AJMC^®. February 24, 2025. Accessed March 2, 2025. https://www.ajmc.com/view/health-system-policy-failures-drive-cervical-cancer-disparities-in-rural-south