Rural-Urban Disparities in Colorectal Cancer Screening Persist

Colorectal cancer (CRC) screening rates remain lower in rural areas compared with urban communities, according to a new analysis of more than 535,000 adults in the US. Although education, income, insurance coverage, and provider access explain part of the disparity, more than 70% of the gap remains unaccounted for, pointing to deeper structural and cultural barriers that require equity-focused interventions.

This analysis is published in Cancer Causes & Control.

National survey data show rural residents are less likely to receive colorectal cancer screening, with socioeconomic and structural barriers driving the gap. | Image credit: Thitiporn - stock.adobe.com

“Despite national efforts to increase CRC screening, significant rural–urban disparities persist across the United States,” wrote the researchers of the study. “While previous studies have identified individual and socioeconomic barriers contributing to these disparities, limited research has quantified how much of the gap is due to differences in population characteristics vs. systemic or contextual inequities.”

Rural populations face a higher burden of CRC mortality than their urban counterparts, yet research and policy efforts have largely focused on screening access while paying less attention to other key outcomes.2 One systematic review of 39 studies examining CRC screening, stage at diagnosis, treatment, and survivorship care found that rural individuals were significantly less likely to undergo any type of CRC screening (pooled OR, 0.81; 95% CI, 0.76-0.86). These findings highlight the need for more comprehensive research on multilevel determinants of CRC outcomes in rural communities to guide interventions.

In this study, the researchers aimed to evaluate the underlying factors that contribute to geographic inequities in CRC screening rates.1

The study analyzed data from 535,568 adults who participated in the Behavioral Risk Factor Surveillance System between 2019 and 2023. CRC screening status was defined as a binary outcome, indicating whether participants were up to date with screening recommendations. To further investigate the drivers of rural-urban disparities, the researchers quantified how much of the observed screening gap could be explained by measurable factors such as age, sex, race/ethnicity, education, income, health insurance coverage, and access to a personal health care provider, compared with unmeasured structural or contextual influences.

Overall, 73.0% of eligible adults reported being up to date with CRC screening, with notable differences between urban and rural populations. Screening prevalence was higher among urban residents at 77.7% compared with 74.4% among rural residents.

Decomposition analysis revealed that 27.5% of the rural-urban disparity could be explained by measurable factors, including age, sex, race/ethnicity, education, income, insurance coverage, and access to a personal health care provider. Among these, educational attainment and income contributed most to the explained gap.

However, 72.5% of the disparity remained unexplained, suggesting that structural, cultural, and health care system–level factors likely play a major role in driving the lower screening rates observed in rural communities.

However, the researchers noted some limitations. First, the study relied on self-reported data, which may have introduced recall bias or social desirability bias, potentially affecting the accuracy of reported screening rates. Second, although Blinder-Oaxaca decomposition analysis quantified the contribution of measurable factors to rural-urban disparities, it could not account for all structural, institutional, cultural, or psychological determinants that may influence CRC screening behavior. These unmeasured factors likely contributed to the majority of the observed disparity, acknowledged the researchers.

Despite these limitations, the researchers believe the study highlights rural-urban CRC screening disparities that exist and call for multifaceted and equity-based interventions to help address this gap.

“In conclusion, our study highlights that rural–urban disparities in colorectal cancer screening persist in the United States, with most of the difference driven by unmeasured factors beyond sociodemographic and access-related variables,” wrote the researchers.

References

1. Owusu DN, Mensah EA, Mamudu S, et al. Rural-urban disparities in colorectal cancer screening in United States: Blinder-Oaxaca decomposition analysis of BRFSS data. Cancer Causes Control. Published online September 19, 2025. doi:10.1007/s10552-025-02071-7

2. Sepassi A, Li M, Zell JA, et al. Rural-urban disparities in colorectal cancer screening, diagnosis, treatment, and survivorship care: a systematic review and meta-analysis. Oncologist. 2024;29(4):e431-e446. doi:10.1093/oncolo/oyad347