Temporal trends in rural vs urban colon cancer mortality in Texas: A SEER database analysis from 2012 to 2021.
Authors: Sukhera Ahmed Bashir , Rodriguez Vazquez Jorge , Erazo Gloria , Fasola Ooreoluwa , Ullah Mosffa , Mathew Merry , Ogedegbe Oboseh John , Tabowei Godfrey , Sanchez Asley , Garza John 
Published: January 2025

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Background:
Colorectal cancer is a major concern for the U.S. healthcare system, being the fourth most common cancer by incidence in the country with 152,810 cases in 2024. Measuring the burden this disease places on patients and health resources may serve to optimize our approach to the detection, management and resource allocation for combating this ailment.
Methods:
Our study is a population-based study cohort of colon cancer deaths in Texas. We queried the National Cancer Institute Surveillance, Epidemiology and End Results Program (SEER) for colon cancer deaths in Texas over the most recent available decade, 2012 through 2021. The National Center for Health Statistics Urban-Rural Classification Scheme was used to classify counties according to the 2013 US Census classification: urban (≥ 50,000) and rural (< 50,000). We calculated age-adjusted mortality rates (AAMRs) per 100,000 population using the direct standardization method based on the age group weights from the 2000 standard US population. Confidence intervals for AAMR were derived by estimating the standard error as the AAMR divided by square root of number of mortalities. Differences between AAMR were tested by comparing the 95% confidence intervals (95% CI) for the individual rates. The annual percent change (APC) in AAMR was tested using negative binomial regression. Subgroup analyses included age group, sex, and race/ethnicity.
Results:
Over the study period, 10.8% of the study population lived in rural areas and 89.2% lived in urban areas. A total of 33,591 colon-cancer deaths were reported during the study period with 5,423 (16.1%) in rural counties and 28,168 (83.9%) in urban counties. At the beginning of the study period the rural AAMR (13.9 [12.7 to 15.1]) was significantly higher than urban AAMR 12.1 [95% CI 11.7 - 12.6]). The rural AAMR rose significantly over the study period (APC 1.1% [95% CI 0.3% - 1.9%]; p = 0.0050) to AAMR 14.9 (95% CI 13.7 to 16.1). In contrast, the urban AAMR did not change over study period (APC -0.3% [95% CI -0.7 to 0.1]; p = 0.1444) and was equal to the initial AAMR 12.1 (95% CI 11.7 to 12.5). On subgroup analyses, males, people ages 25-64 years, Hispanics, Non-Hispanic Blacks, Non-Hispanic Asians, and Non-Hispanic Native Americans in rural areas each had significant and increasing trends in AAMR.
Conclusions:
Our analysis revealed an increase in AAMR in rural counties of Texas, reflecting a concerning trend with regard to colorectal cancer in this region. This may be due to higher poverty rates, lower level of education, more distance from healthcare facilities and difficulties with transportation faced by rural counties. Furthermore, rural areas also report higher rates of obesity and poor dietary habits. Rural areas also face a shortage of Primary Care Physicians (PCP’s), with metropolitan counties retaining 1.7 times as many PCP’s as rural counties, and 82.5% of counties without a PCP being rural.