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Phrases like “health equity” and “social determinants of health” are typically associated with populations that are underserved due to race, ethnicity, or socioeconomic status. But geography plays an equally important role in a patient’s cancer outcomes.
Most of the land mass in the United States is categorized as "rural"—with some of that land being further distinguished as "frontier"—yet only 14-20 percent of the U.S. population lives in these areas. Due to lower population density, rural and frontier communities typically have smaller populations spread out over larger areas than densely populated urban areas. However, definitions of "rural" and "frontier" vary across U.S. government agencies as well as cancer centers. Like several National Cancer Institute (NCI)-Designated Cancer Centers, the Fred & Pamela Buffett Cancer Center uses the rural-urban commuting areas (RUCAs) system to identify very remote areas that are considered frontier. Under the RUCA definition, areas are categorized based on measures of urbanization, population density, and daily work commuting.
Eliminating Barriers, Improving Outcomes
Individuals residing in rural and frontier areas experience higher rates of cancer morbidity and mortality compared to those who live in urban locations. A primary driver of these poor cancer outcomes is limited access at key stages across the cancer care continuum, from prevention and risk reduction strategies to clinical trial participation and treatment. Barriers to accessing health services in rural areas include lack of transportation, fewer health care facilities, and insufficient insurance coverage. The NCI's Division of Cancer Control & Population Sciences notes that lifestyle and behavioral differences between rural and urban populations, including higher rates of obesity, tobacco use, and alcohol consumption, lower levels of physical activity, and lower HPV vaccination rates in rural areas further exacerbate cancer health disparities.
At my own institution, I have witnessed these disparities firsthand. Located in Omaha, Buffett Cancer Center serves all 93 counties of the state of Nebraska. As the 16th largest state by land area, Nebraska is home to over 2 million people and primarily consists of rural and frontier communities across the Great Plains. Nearly 80 percent of the patients treated at Buffett Cancer Center live within this area, which spans over 77,000 square miles.
As I considered potential focus areas for my AACI Presidential Initiative, I wanted to address an urgent need, not just for my cancer center, but for AACI cancer centers located in predominantly rural states such as Alabama, Arkansas, Kentucky, Maine, Mississippi, New Hampshire, Vermont, and West Virginia, and that serve rural and frontier populations.
Applying Existing Catchment Area Research to Address Cancer Disparities
I was inspired in part by a previous AACI presidential initiative. For her Mitigating Cancer Disparities initiative, Karen E. Knudsen, MBA, PhD, aimed to increase awareness and understanding of understudied geographies and develop strategies to improve cancer outcomes in these regions.
The initiative culminated in the publication of "Assessing the Coverage of US Cancer Center Primary Catchment Areas" in Cancer Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research. It also laid the foundation for more recent AACI projects, including the Catchment Area Research and Data Science (CARDS) listserv and webinars, and the AACI Catchment Area Data Excellence (CADEx) Conference.
Presidential Initiative Goals and Timeline
Using a similar framework, I am proposing the following goals for my presidential initiative, Addressing the Crisis of Rural Cancer Health in Our Nation:
- Map access to cancer services, including prevention tools, participation in clinical trials, and cancer education, as well as the outcomes of these services, across the nation
- Develop a national overview of cancer morbidity and mortality across the U.S., stratified by rural and frontier status
- Enhance our understanding of social determinants of health, such as health insurance coverage, access to reliable transportation, and education, as they relate to an individual’s likelihood of being screened, diagnosed with, or treated for cancer while living in the rural U.S.
- Identify best practices for decreasing morbidity and mortality from cancer in rural regions of the U.S. at a summit of NCI-Designated Cancer Centers, to be held in the summer of 2027
- Establish an AACI oversight committee comprised of rural experts from NCI-Designated Cancer Centers and community representatives to guide implementation and updates of best practices
To accomplish these goals, I have also developed a timeline that highlights major milestones for the project during my two-year term as AACI president.
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November 2025: Appoint steering committee
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January 2026: Develop and distribute survey to AACI members
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March 2026: Begin analyzing survey results
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June 2026: Complete analysis, begin to prepare manuscript, and begin planning for 2027 rural summit
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October 2026: Information on rural summit released to AACI members
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January 2027: Begin forming National Rural Cancer Committee
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August 2027: Release manuscript and guidelines during rural summit
Thank you to everyone who has already reached out to express interest in joining the steering committee and participating in the rural summit. Special thanks to Shinobu Watanabe-Galloway, PhD, associate director of community outreach and engagement at the Buffett Cancer Center, for her support in preparing this AACI Commentary.
As I look ahead to the next two years as AACI president, I’m excited to collaborate with cancer centers across the country to accelerate progress against cancer. I look forward to working with you all to improve access to prevention, screening, and education; cutting-edge clinical trials; and high-quality cancer care for all Americans – no matter where they live.
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