Rural geography, demographics, and cultures are diverse, ranging from the rolling hills of Appalachia to the farmlands of the Midwest to the deserts of the American Southwest. Approximately 14% of Americans and 25% of older Americans reside in rural areas, translating into 46.1 million individuals living in 72% of the US landmass.¹ Cancer incidence, mortality, and treatment disparities in rural areas have been well documented. In recent years, cancer incidence in rural areas has outpaced urban areas.² Cancer mortality across the US has improved overall; however, gains in rural areas have lagged behind urban.^3,4 Within the top three most common genitourinary cancers (prostate, bladder, and kidney), there is variation in rural incidence and mortality by organ site. Bladder and kidney cancers have a higher incidence in rural areas as compared to urban. In contrast, prostate cancer mortality has declined across the US but to a greater degree in rural areas.^2,5

The reasons for rural cancer disparities are multifaceted and include lifestyle factors, social determinants of health, and health care access. Lifestyle factors are important across the entire cancer continuum from diagnosis to treatment and survivorship. Older adults living in rural areas have higher rates of smoking and obesity and lower rates of adequate physical activity.⁶ These lifestyle factors may drive an increased incidence of smoking-related malignancies like bladder cancer and obesity-related malignancies like kidney cancer in rural areas. Physical activity reduces the risk of multiple cancers and enhances cancer treatment tolerability. Rural residents have higher rates of baseline coexisting chronic conditions like diabetes. As part of cancer survivorship, physical activity may help to prevent new chronic conditions caused by chemotherapy or permanent disability following major cancer surgery.

Rural residents have greater social needs than their urban counterparts. Social determinants of health, defined by the World Health Organization as “the conditions in which people are born, grow, live, work, and age,” contribute to rural health disparities. One key social determinant of health is equitable access to health care for primary care and specialty urologic and oncologic care. Rural residents have lower rates of car ownership, rely on social networks for transportation, and travel longer distances to access urologic care.⁷ A recent study of the Pennsylvania Cancer Registry showed an association between high primary care density and localized bladder cancer at diagnosis, but there was no difference in stage at diagnosis due to urologist density.⁸ These findings highlight the important role that primary care access could play in subsequent cancer diagnosis and rural disparities in cancer diagnosis.

Primary care is often the gatekeeper for referrals to urology and oncology specialists, but rural primary care physicians need ready access to specialists to refer to. Urologists are the front line in the initial diagnosis and treatment of urologic cancers, but the US is facing a devastating urologist shortage in rural areas, which is poised to exacerbate existing disparities. We previously analyzed AUA Census data and found that the rural urology workforce is aging while the average age of the urban workforce has remained stable, suggesting that new graduates are choosing to practice in urban centers.⁹ Rural urologists in the AUA Census noted greater difficulties filling job vacancies than urban urologists, and most rural counties have zero urologists, specifically in large swaths of the Midwest, Western frontier areas, and the rural South (Figure).

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A complicating factor is that rurality is difficult to define. Frequently used objective measures are based on population size or proximity to urban centers, although these types of measures do not adequately capture rural culture, demographics, and geographies, which vary across the country. Rural communities are also becoming more racially and ethnically diverse.¹⁰ Changing demographics in rural areas have important implications for equitable cancer care delivery and future rural health policy.

Eliminating rural urologic cancer disparities is an important health equity issue and will require a multifaceted approach incorporating health policy that expands clinical care access and addresses social needs. Video and telephone telehealth expansion and reimbursement during the COVID-19 pandemic has been a boon for rural residents, offering the ability to connect with urologists and other specialists without incurring travel time and out-of-pocket costs. Recent legislation efforts, such as the CONNECT for Health Act, could protect and expand COVID-19 telehealth provisions. The act also addresses the social need of expanded broadband internet access to enable telehealth in rural areas. To address the rural urology workforce shortage, legislation to attract urologists to rural practice via student loan repayment (Specialty Physicians Advancing Rural Care Act) was introduced into Congress in 2023 with support from the American Urological Association. The Biden–Harris administration committed $11 million to expand rural-based primary care residency programs; expanding urology residency programs in rural areas may encourage subsequent rural practice.

To improve specialty clinical care in rural central Pennsylvania, our institution implemented the Project ECHO remote learning model to educate rural primary care physicians about specialty topics through interactive virtual sessions. We also established mobile health units to bring basic health care, screenings, and research studies to people in remote areas of Pennsylvania. Drawing on the rich social networks of rural areas, Pennsylvania’s federally qualified health centers engage community health workers to help rural patients navigate the health system for certain conditions. Models based on these examples could enhance urologic care in rural areas.

Sadly, many conversations about rural places underline negative aspects like health disparities and social needs while ignoring what is positive and special. Since 2020, rural areas have seen an uptick in population growth. Having myself grown up in rural Wisconsin and now with a decade of urologic practice in rural Pennsylvania, I am constantly struck by the resplendent landscape of my commute, the tight social fabric that surrounds my patients, and the meaning that comes from serving a community while being part of one. Although there is much to be done to advance rural health equity, we should draw on the unique strengths, diversity, and culture of these special places.