New research tracking county-level cancer deaths from 1981 to 2019 finds that while national cancer mortality has fallen substantially, improvements are uneven across the United States. The analysis used CDC mortality records covering more than 21 million cancer deaths and reveals sharper declines in urban, coastal, and higher-income counties compared with smaller reductions in rural and lower-income areas. Researchers warn these diverging trends may reflect differences in prevention, screening, treatment access, and the speed at which life-saving practices spread. The study calls for more targeted investigation into the geographic and socioeconomic gaps behind the uneven progress.
The team examined nearly 3,000 counties to measure how quickly cancer death rates changed over time, drawing on long-term national mortality data. Overall, the U.S. saw about a 32% decline in cancer mortality between 1991 and 2019, but that national average masks large local differences. Coastal and major metropolitan areas recorded the most dramatic drops, while interior, rural counties lagged behind. That geographic split shows where public health gains have concentrated and where work remains.
Arthur G. Cosby, the study’s lead author, framed the findings in plain terms about regional variation. “In a complex nation such as the U.S., we should not be too surprised that there are large differences in health outcomes shaped by the diversity and variety of local regions and groups,” he said. The researchers highlight that the pace of improvement has not been uniform, and that unequal uptake of prevention and care can widen existing disparities.
The data suggest the gap has grown over time; by 2019 the top 10% highest-income counties showed roughly seven times greater mortality improvement than the lowest-income counties. Major cities along the Atlantic and Pacific frequently sit among the most improved, while many smaller and inland communities see much smaller gains. “The magnitude of the mortality differences between coastal and inland regions, [and] the large differences between places with different income levels and rural/urban places, were larger than I anticipated,” Cosby said. Those contrasts point to structural differences that influence health outcomes over decades.
Investigators point to several plausible drivers behind the stronger declines in wealthier urban counties. Declines in smoking, earlier detection through screening, and improved cancer therapies have all contributed to falling death rates. “Wealthy, metropolitan New York City has been aggressive in instituting tobacco control measures, and the results show,” Cosby noted. “Manhattan had a lung cancer rate of 49 per 100,000 in 1991. By 2019, it cut its rate to 19.6 — a 60% reduction.”
Independent medical observers echoed the importance of prevention and early diagnosis. “More aggressive screening campaigns, including at major medical centers, can diagnose pre-cancers or cancers earlier,” Siegel, who was not involved in the study, said. Access to major medical centers, public health campaigns, and investments in prevention tend to concentrate in wealthier urban settings, which can accelerate improvements. Lifestyle changes and reduced environmental exposures in some communities likely also play a role.
The authors acknowledge clear limitations to an ecological, county-level study and caution about overinterpreting the findings for individuals. Because the analysis uses aggregated county data, individual risk factors and personal healthcare access may differ from the community-level picture. “There are many limitations associated with the use of death certificates in research, such as accuracy of cause of death, possible multiple causes and changes in medical explanation for death over time,” Cosby said. Those measurement issues can blunt but not erase the broad geographic patterns observed.
Given the uneven pace of adoption for effective interventions, the team urges further research that drills down into local causes and potential solutions. “The link between improving health and increasing disparities is poorly understood. I am pursuing that question now,” he added. “The varying speed of adoption of life-saving interventions between geographic places may produce increasing disparities,” Cosby said. “It is possible to have a situation where nearly all places are improving their cancer mortality, but at much different rates.”
