Rural and urban disparities in cancer mortality in Texas during the COVID-19 pandemic.

Abstract

e22504 Background: Populations residing in rural regions (in comparison to urban) often experience higher cancer mortality rates. The COVID-19 pandemic introduced significant disruptions to healthcare systems and mortality patterns. This study investigates the differential impact of the COVID-19 pandemic on cancer mortality trends in Texas, specifically examining shifts in rural-urban disparities stratified by age and sex. Methods: We conducted a retrospective population-based analysis of malignant cancer (C00-C97) deaths in counties of Texas from 2018 to 2023 using CDC WONDER mortality data; stratified by sex, age [middle-aged (45-64 yrs), older adults (65-84 years)], and county’s classification (rural or urban). The study period was divided into pre-COVID (2018-2019) and COVID (2020-2023) eras. Annual estimated populations were ascertained by county, age, and sex-to document mortality rates per 100,000 persons. We computed ratios between rural-to-urban mortality rates for both periods (pre vs during COVID). Statistical significance for the time-periods and geographic differences in mean mortality rate ratios were assessed using generalized linear models, where P<0.05 was deemed significant. Results: Throughout the six-year study period there were a total of 185,949 cancer deaths [55% male, 69.1% older adults] in Texas US. In the pre-COVID era, average annual number of deaths were 29,788, whereas the COVID era experienced on average 41,124 deaths per year. Significant declines in cancer mortality rates were observed across all demographic groups in rural and urban counties during the COVID period compared to the pre-COVID period, with steeper declines observed in rural populations (P<0.001). Furthermore, older males the rural-urban ratio was 1.36 pre-COVID vs 1.07 during COVID (ratio differences, P<0.001). Whereas, for older females the rural-urban ratio was 1.33 pre-COVID vs 0.99 during COVID (ratio differences, P<0.001). Hence the largest narrowing of cancer mortality rural-urban rate ratios from pre-COVID to COVID era was observed among older adults, where the rural-urban ratio is approximately one-to-one. Conclusions: While cancer mortality rates appeared to decrease during the pandemic, the significant narrowing of the rural-urban gap approaching parity in older populations likely reflects the competing risk of COVID-19 mortality, which disproportionately affected rural and older populations, alongside potential under-diagnosis due to screening disruptions. These findings suggest a “masking” of cancer burdens in rural Texas rather than a true improvement in oncologic equity. Future research must account for excess death modeling to understand the true latent burden of cancer in the post-pandemic rural landscape.