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Cancer disparities in the context of rurality: risk factors and screening across various U.S. rural classification codes

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Abstract

Purpose

Prior cancer research is limited by inconsistencies in defining rurality. The purpose of this study was to describe the prevalence of cancer risk factors and cancer screening behaviors across various county-based rural classification codes, including measures reflecting a continuum, to inform our understanding of cancer disparities according to the extent of rurality.

Methods

Using an ecological cross-sectional design, we examined differences in cancer risk factors and cancer screening behaviors from the Behavioral Risk Factor Surveillance System and National Health Interview Survey (2008–2013) across rural counties and between rural and urban counties using four rural–urban classification codes for counties and county-equivalents in 2013: U.S. Office of Management and Budget, National Center for Health Statistics, USDA Economic Research Service’s rural–urban continuum codes, and Urban Influence Codes.

Results

Although a rural-to-urban gradient was not consistently evident across all classification codes, the prevalence of smoking, obesity, physical inactivity, and binge alcohol use increased (all ptrend < 0.03), while colorectal, cervical and breast cancer screening decreased (all ptrend < 0.001) with increasing rurality. Differences in the prevalence of risk factors and screening behaviors across rural areas were greater than differences between rural and urban counties for obesity (2.4% vs. 1.5%), physical activity (2.9% vs. 2.5%), binge alcohol use (3.4% vs. 0.4%), cervical cancer screening (6.8% vs. 4.0%), and colorectal cancer screening (4.4% vs. 3.8%).

Conclusions

Rural cancer disparities persist across multiple rural–urban classification codes, with marked variation in cancer risk factors and screening evident within rural regions. Focusing only on a rural–urban dichotomy may not sufficiently capture subpopulations of rural residents at greater risk for cancer and cancer-related mortality.

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Data availability

The datasets analyzed during the current study are available in the State Cancer Profiles website, https://statecancerprofiles.cancer.gov/

References

  1. Henley SJ, Anderson RN, Thomas CC, Massetti GM, Peaker B, Richardson LC (2002) Invasive cancer incidence, 2004–2013, and deaths, 2006–2015, in nonmetropolitan and metropolitan counties—United States. Morb Mortal Wkly Rep Surveill Summ Wash DC 2017(66):1–13

    Google Scholar 

  2. Blake KD, Moss JL, Gaysynsky A, Srinivasan S, Croyle RT (2017) Making the case for investment in rural cancer control: an analysis of rural cancer incidence, mortality, and funding trends. Cancer Epidemiol Biomark Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol 26:992–997

    Article  Google Scholar 

  3. Zahnd WE, James AS, Jenkins WD, Izadi SR, Fogleman AJ, Steward DE, Colditz GA, Brard L (2018) Rural-urban differences in cancer incidence and trends in the United States. Cancer Epidemiol Biomark Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol 27:1265–1274

    Article  Google Scholar 

  4. Siegel RL, Miller KD, Jemal A (2020) Cancer statistics, 2020. CA Cancer J Clin 70:7–30

    Article  PubMed  Google Scholar 

  5. Charlton M, Schlichting J, Chioreso C, Ward M, Vikas P (2015) Challenges of rural cancer care in the United States. Oncol Williston Park N 29:633–640

    Google Scholar 

  6. Agency for Healthcare Research and Quality (2015) 2014 national healthcare quality and disparities report chartbook on rural health care. AHRQ Pub. No. 15–0007–9-EF [Internet]. 2015. https://www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/ruralhealth/index.htmlexternalicon

  7. Meilleur A, Subramanian SV, Plascak JJ, Fisher JL, Paskett ED, Lamont EB (2013) Rural residence and cancer outcomes in the United States: issues and challenges. Cancer Epidemiol Biomark Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol 22:1657–1667

    Article  Google Scholar 

  8. Bennett KJ, Probst JC, Bellinger JD (2012) Receipt of cancer screening services: surprising results for some rural minorities. J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc 28:63–72

    Article  Google Scholar 

  9. Nuño T, Gerald JK, Harris R, Martinez ME, Estrada A, García F (2012) Comparison of breast and cervical cancer screening utilization among rural and urban Hispanic and American Indian women in the Southwestern United States. Cancer Causes Control CCC 23:1333–1341

    Article  PubMed  Google Scholar 

  10. Fan L, Mohile S, Zhang N, Fiscella K, Noyes K (2012) Self-reported cancer screening among elderly Medicare beneficiaries: a rural-urban comparison. J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc 28:312–319

    Article  CAS  Google Scholar 

  11. Doescher MP, Jackson JE (2009) Trends in cervical and breast cancer screening practices among women in rural and urban areas of the United States. J Public Health Manag Pract JPHMP 15:200–209

    Article  PubMed  Google Scholar 

  12. Colditz GA, Wolin KY, Gehlert S (2012) Applying what we know to accelerate cancer prevention. Sci Transl Med 4:127rv4

    Article  PubMed  PubMed Central  Google Scholar 

  13. Garcia MC, Faul M, Massetti G, Thomas CC, Hong Y, Bauer UE, Iademarco MF (2002) Reducing potentially excess deaths from the five leading causes of death in the rural United States. Morb Mortal Wkly Rep Surveill Summ Wash DC 2017(66):1–7

    Google Scholar 

  14. Matthews KA, Croft JB, Liu Y, Lu H, Kanny D, Wheaton AG, Cunningham TJ, Khan LK, Caraballo RS, Holt JB, Eke PI, Giles WH (2002) Health-related behaviors by urban-rural county classification—United States, 2013. Morb Mortal Wkly Rep Surveill Summ Wash DC 2017(66):1–8

    Google Scholar 

  15. Bolin JN, Bellamy GR, Ferdinand AO, Vuong AM, Kash BA, Schulze A, Helduser JW (2015) Rural healthy people 2020: new decade, same challenges. J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc 31:326–333

    Article  Google Scholar 

  16. Brawley OW (2011) Cancer disparities: the scope of the problem and possible solutions. In: Cancer disparities

  17. Woods M (2015) Conceptualizing rural areas in metropolitan society: a rural view

  18. Bennett KJ, Borders TF, Holmes GM, Kozhimannil KB, Ziller E (2019) What is rural? Challenges and implications of definitions that inadequately encompass rural people and places. Health Aff Proj Hope 38:1985–1992

    Article  Google Scholar 

  19. Long JC, Delamater PL, Holmes GM (2021) Which definition of rurality should I use? The relative performance of 8 federal rural definitions in identifying rural-urban disparities. Med Care 59:S413–S419

    Article  PubMed  PubMed Central  Google Scholar 

  20. Zahnd WE, Mueller-Luckey GS, Fogleman AJ, Jenkins WD (2019) Rurality and health in the United States: do our measures and methods capture our intent? J Health Care Poor Underserved 30:70–79

    Article  PubMed  Google Scholar 

  21. Hart LG, Larson EH, Lishner DM (2005) Rural definitions for health policy and research. Am J Public Health 95:1149–1155

    Article  PubMed  PubMed Central  Google Scholar 

  22. Coburn AF, MacKinney AC, McBride TD, Mueller KJ, Slifkin RT, Wakefield MK (2007) Choosing rural definitions: implications for health policy. [Internet]. Issue Brief 2:1–8

  23. Waldorff B, Kim A (2015) Defining and measuring rurality in the US: from typologies to continuous indices

  24. Macintyre S, Ellaway A, Cummins S (2002) Place effects on health: how can we conceptualise, operationalise and measure them? Soc Sci Med 55:125–139

    Article  PubMed  Google Scholar 

  25. Zahnd WE, Askelson N, Vanderpool RC, Stradtman L, Edward J, Farris PE, Petermann V, Eberth JM (2019) Challenges of using nationally representative, population-based surveys to assess rural cancer disparities. Prev Med 129S:105812

    Article  PubMed  Google Scholar 

  26. Cromartie, J. Historical development of ERS rural-urban classification systems [Internet]. https://sites.nationalacademies.org/cs/groups/dbassesite/documents/webpage/dbasse_169814.pdf

  27. U.S. Census (2016) U.S. Census reference files [Internet]. https://www.census.gov/geographies/reference-files/2016/demo/popest/2016-fips.html

  28. Ingram DD, Franco SJ (2014) 2013 NCHS urban-rural classification scheme for counties

  29. Baer LD, Johnson-Webb KD, Gesler WM (1997) What is rural? A focus on urban influence codes. J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc 13:329–333

    Article  CAS  Google Scholar 

  30. Economic Research Service USDA (2003) ERS/USDA urban influence codes documentation [Internet]. https://www.ers.usda.gov/data-products/urban-influence-codes/documentation/

  31. U.S. Department of Health and Human Services (2014) The health consequences of smoking—50 years of progress: a report of the surgeon general

  32. Befort CA, Nazir N, Perri MG (2012) Prevalence of obesity among adults from rural and urban areas of the United States: findings from NHANES (2005–2008). J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc 28:392–397

    Article  Google Scholar 

  33. Davis AM, Bennett KJ, Befort C, Nollen N (2011) Obesity and related health behaviors among urban and rural children in the United States: data from the national health and nutrition examination survey 2003–2004 and 2005–2006. J Pediatr Psychol 36:669–676

    Article  PubMed  PubMed Central  Google Scholar 

  34. Johnson JA, Johnson AM (2015) Urban-rural differences in childhood and adolescent obesity in the United States: a systematic review and meta-analysis. Child Obes Print 11:233–241

    Article  Google Scholar 

  35. Patterson PD, Moore CG, Probst JC, Shinogle JA (2004) Obesity and physical inactivity in rural America. J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc 20:151–159

    Article  Google Scholar 

  36. Gfroerer JC, Larson SL, Colliver JD (2007) Drug use patterns and trends in rural communities. J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc 23(Suppl):10–15

    Article  Google Scholar 

  37. Borders TF, Booth BM (2007) Rural, suburban, and urban variations in alcohol consumption in the United States: findings from the national epidemiologic survey on alcohol and related conditions. J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc 23:314–321

    Article  Google Scholar 

  38. Jackson JE, Doescher MP, Hart LG (2006) Problem drinking: rural and urban trends in America, 1995/1997 to 2003. Prev Med 43:122–124

    Article  PubMed  Google Scholar 

  39. National Cancer Institute, Centers for Disease Control. State cancer profiles [Internet]. [cited 2021 Dec 13]. https://statecancerprofiles.cancer.gov/

  40. Raghunathan TE, Dawei X, Schenker N, Parsons VL, Davis WW, Dodd KW, Feuer EJ (2007) Combining information from two surveys to estimate county-level prevalence rates of cancer risk factors and screening. J Am Statistical Assoc. 102:474–486

    Article  CAS  Google Scholar 

  41. Liu B, Parsons V, Feuer EJ, Pan Q, Town M, Raghunathan TE, Schenker N, Xie D (2019) Small area estimation of cancer risk factors and screening behaviors in US counties by combining two large national health surveys. Prev Chronic Dis 16:E119

    PubMed  PubMed Central  Google Scholar 

  42. National Cancer Institute. Small area estimates for cancer-related measures [Internet]. sae.cancer.gov

  43. U.S. Census Bureau’s Population Estimates Program. https://www.cdc.gov/diabetes/data/countydata/countydataindicators.html

  44. Rao JNK (2003) Small area estimation. John Wiley & Sons Inc, Hoboken

    Book  Google Scholar 

  45. Cadwell BL, Thompson TJ, Boyle JP, Barker LE (2005) Bayesian small area estimates of diabetes prevalence by US County. J Data Sci 8:173–88

    Google Scholar 

  46. Barker LE, Thompson TJ, Kirtland KA, Boyle JP, Geiss LS, McCauley MM, Albright AL (2013) Bayesian small area estimates of diabetes incidence by United States County, 2009. J Data Sci JDS 11:269–280

    PubMed  Google Scholar 

  47. Institute for Health Metrics and Evaluation (2015) United States alcohol use prevalence by County 2002–2012

  48. Dwyer-Lindgren L, Flaxman AD, Ng M, Hansen GM, Murray CJL, Mokdad AH (2015) Drinking patterns in US counties from 2002 to 2012. Am J Public Health 105:1120–1127

    Article  PubMed  PubMed Central  Google Scholar 

  49. Park C, Hsiung JT, Soohoo M, Streja E. Choosing wisely: using the appropriate statistical test for trend in SAS [Internet]. [cited 2022 Apr 25]. https://www.lexjansen.com/wuss/2019/175_Final_Paper_PDF.pdf

  50. Lundeen EA, Park S, Pan L, O’Toole T, Matthews K, Blanck HM (2018) Obesity prevalence among adults living in metropolitan and nonmetropolitan counties—United States, 2016. MMWR Morb Mortal Wkly Rep 67:653–658

    Article  PubMed  PubMed Central  Google Scholar 

  51. Whitfield GP, Carlson SA, Ussery EN, Fulton JE, Galuska DA, Petersen R (2019) Trends in meeting physical activity guidelines among urban and rural dwelling adults—United States, 2008–2017. MMWR Morb Mortal Wkly Rep 68:513–518

    Article  PubMed  PubMed Central  Google Scholar 

  52. Doogan NJ, Roberts ME, Wewers ME, Stanton CA, Keith DR, Gaalema DE, Kurti AN, Redner R, Cepeda-Benito A, Bunn JY, Lopez AA, Higgins ST (2017) A growing geographic disparity: rural and urban cigarette smoking trends in the United States. Prev Med 104:79–85

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. Dixon MA, Chartier KG (2016) Alcohol use patterns among urban and rural residents: demographic and social influences. Alcohol Res Curr Rev 38:69–77

    Google Scholar 

  54. Cohen SA, Cook SK, Sando TA, Sabik NJ (2018) What aspects of rural life contribute to rural-urban health disparities in older adults? Evidence from a national survey. J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc 34:293–303

    Article  Google Scholar 

  55. Shete S, Deng Y, Shannon J, Faseru B, Middleton D, Iachan R, Bernardo B, Balkrishnan R, Kim SJ, Huang B, Millar MM, Fuemmler B et al (2021) Differences in breast and colorectal cancer screening adherence among women residing in urban and rural communities in the United States. JAMA Netw Open 4:e2128000

    Article  PubMed  PubMed Central  Google Scholar 

  56. Lutgendorf SK, Ramirez E, Schrepf A, Valentine MC, Charlton M, Zimmerman MB, Goodheart MJ, Zia S, Sood AK, Thaker PH (2021) Rural residence is related to shorter survival in epithelial ovarian cancer patients. Gynecol Oncol 163:22–28

    Article  PubMed  Google Scholar 

  57. Thomson MD, Williams AR, Sutton AL, Tossas KY, Garrett C, Sheppard VB (2021) Engaging rural communities in cancer prevention and control research: development and preliminary insights from a community-based research registry. Cancer Med 10:7726–7734

    Article  PubMed  PubMed Central  Google Scholar 

  58. Johnson KJ, Wang X, Barnes JM, Delavar A (2021) Associations between geographic residence and US adolescent and young adult cancer stage and survival. Cancer 127:3640–3650

    Article  PubMed  Google Scholar 

  59. Yaghjyan L, Cogle CR, Deng G, Yang J, Jackson P, Hardt N, Hall J, Mao L (2019) Continuous rural-urban coding for cancer disparity studies: is it appropriate for statistical analysis? Int J Environ Res Public Health 16:1076

    Article  PubMed Central  Google Scholar 

  60. Bennette C, Vickers A (2012) Against quantiles: categorization of continuous variables in epidemiologic research, and its discontents. BMC Med Res Methodol 12:21

    Article  PubMed  PubMed Central  Google Scholar 

  61. Hall SA, Kaufman JS, Ricketts TC (2006) Defining urban and rural areas in U.S. epidemiologic studies. J Urban Health Bull NY Acad Med 83:162–75

    Article  Google Scholar 

  62. Cossman RE, Cossman JS, Cosby AG, Reavis RM (2008) Reconsidering the rural-urban continuum in rural health research: A test of stable relationships using mortality as a health measure. Popul Res Policy Rev 27:459–476

    Article  Google Scholar 

  63. Kenny DA, Mannetti L, Pierro A, Livi S, Kashy DA (2002) The statistical analysis of data from small groups. J Pers Soc Psychol 83:126–137

    Article  PubMed  Google Scholar 

  64. Fok CCT, Henry D, Allen J (2015) Maybe small is too small a term: introduction to advancing small sample prevention science. Prev Sci Off J Soc Prev Res 16:943–949

    Article  Google Scholar 

  65. Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry/Geospatial Research Analysis, and Services Program. CDC/ATSDR Social Vulnerability Index 2020 [Internet]. 2020 [cited 2022 Feb 2]. https://www.atsdr.cdc.gov/placeandhealth/svi/data_documentation_download.html#:~:text=Our%20suggested%20citation%20for%20use,%5BInsert%20US%20or%20State%5D

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Acknowledgements

The authors assume full responsibility for analyses and interpretation of these data. Dr. Nemeth is funded by National Cancer Institute career development grant 1K07CA216321-01A1.

Funding

No funding was received to assist with the preparation of this manuscript. Dr. Nemeth is funded by NCI career development grant 1K07CA216321-01A1.

Author information

Authors and Affiliations

  1. Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, 909 Fee Road, East Lansing, MI, 48824, USA

    Kelly A. Hirko

  2. Department of Preventive Medicine and Population Health and Sealy Center On Aging, University of Texas Medical Branch, Galveston, TX, USA

    Huiwen Xu

  3. Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA

    Laura Q. Rogers & Monica L. Baskin

  4. Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA

    Michelle Y. Martin

  5. Department of Family and Community Medicine, Penn State College of Medicine, Hershey, PA, USA

    Siddhartha Roy

  6. Department of Pharmaceutical Systems & Policy, West Virginia University, Morgantown, WV, USA

    Kimberly M. Kelly

  7. Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA

    Shannon M. Christy, Cathy D. Meade & Clement K. Gwede

  8. Division of Health Equities, City of Hope Comprehensive Cancer Center and Beckman Institute, Duarte, CA, USA

    Kimlin Tam Ashing

  9. Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA

    Jean C. Yi

  10. Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Marquita W. Lewis-Thames

  11. Department of Health Disparities Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Qian Lu

  12. Department of Health Behavior and Health Promotion, The Ohio State University College of Public Health, Columbus, OH, USA

    Julianna Nemeth

  13. Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA

    Rachel M. Ceballos

  14. College of Nursing, University of South Florida, Tampa, FL, USA

    Usha Menon

  15. Institute of Social and Economic Research, University of Alaska, Anchorage, AK, USA

    Katie Cueva

  16. Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA

    Karen Yeary

  17. Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA

    Lisa M. Klesges

  18. Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Kassandra I. Alcaraz

  19. Department of Obstetrics, Gynecology & Reproductive Biology, College of Human Medicine, Michigan State University, East Lansing, MI, USA

    Sabrina Ford

Authors
  1. Kelly A. Hirko
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  2. Huiwen Xu
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  3. Laura Q. Rogers
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  4. Michelle Y. Martin
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  5. Siddhartha Roy
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  6. Kimberly M. Kelly
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  7. Shannon M. Christy
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  8. Kimlin Tam Ashing
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  9. Jean C. Yi
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  10. Marquita W. Lewis-Thames
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  11. Cathy D. Meade
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  12. Qian Lu
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  13. Clement K. Gwede
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  14. Julianna Nemeth
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  15. Rachel M. Ceballos
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  16. Usha Menon
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  17. Katie Cueva
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  18. Karen Yeary
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  19. Lisa M. Klesges
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  20. Monica L. Baskin
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  21. Kassandra I. Alcaraz
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  22. Sabrina Ford
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Contributions

All authors contributed to the study conception and design. Material preparation and data collection were performed by Kelly A. Hirko. Data analyses were performed by Huiwen Xu. The first draft of the manuscript was written by Kelly A. Hirko and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript and assume full responsibility for analyses and interpretation of these data.

Corresponding author

Correspondence to Kelly A. Hirko.

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The authors have no relevant financial or non-financial interests to disclose. The authors declare no potential conflicts of interest.

Ethical approval

This is an observational descriptive study using publicly available county-level data. The Michigan State University Institutional Review Board has confirmed that no ethical approval is required.

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Hirko, K.A., Xu, H., Rogers, L.Q. et al. Cancer disparities in the context of rurality: risk factors and screening across various U.S. rural classification codes. Cancer Causes Control 33, 1095–1105 (2022). https://doi.org/10.1007/s10552-022-01599-2

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