---
title: "Persistent Poverty, Race, and Rurality: Disparities in Cancer Mortality in Alabama"
id: "pubmed-42812073"
canonical_url: "https://medichelpline.com/clinical-feed/pubmed-42812073"
content_type: "clinical_feed_article"
specialty: "Oncology"
source_name: "PubMed / NCBI"
source_url: "https://pubmed.ncbi.nlm.nih.gov/42812073/"
doi: "10.1002/cam4.72333"
published_at: "2026-10-01T00:00:00.000Z"
evidence_level: "Journal Article"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Persistent Poverty, Race, and Rurality: Disparities in Cancer Mortality in Alabama
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/pubmed-42812073
- **Specialty:** [Oncology](https://medichelpline.com/clinical-feed/oncology.md)
- **Primary Source:** PubMed / NCBI
- **Source URL:** [Original Journal Publication](https://pubmed.ncbi.nlm.nih.gov/42812073/)
- **DOI:** [10.1002/cam4.72333](https://doi.org/10.1002%2Fcam4.72333)
- **Published At:** 2026-10-01T00:00:00.000Z
- **Evidence Rating:** Journal Article
## Executive GIST (TL;DR)
- Counties and small areas designated as **persistent poverty** are associated with higher cancer mortality; this study evaluates census tract–level persistent poverty and individual survival for common cancers in Alabama. - Retrospective cohort used Alabama Statewide Cancer Registry data for adults with **breast**, **prostate**, **colorectal**, or **lung cancer**. - Exposure: NCI-designated 2010 census tract persistent poverty (tracts with ≥20% population below poverty line for ≥30 years) at time of diagnosis. Outcome: overall survival from diagnosis to death or end of follow-up. - Sequential Cox proportional hazards models estimated associations: unadjusted (PP only), adjusted for demographics, then clinical characteristics, then additionally social determinants (rurality, insurance). - In fully adjusted models, living in a persistent poverty tract was linked to higher hazard of death for **breast cancer** (HR 1.18, 95% CI 1.09–1.27), **prostate cancer** (HR 1.21, 95% CI 1.11–1.31), and **lung cancer** (HR 1.09, 95% CI 1.05–1.14). - Race and rurality were independently associated with increased mortality across cancer types. Those identifying as **Black** and residing in a **rural persistent-poverty tract** experienced the greatest magnitude of risk for all cancers. - A decomposition analysis through race and rurality was performed; detailed results of that decomposition were not reported in the abstract. - Authors conclude that census-tract persistent poverty is associated with worse survival for breast, prostate, and lung cancers in Alabama and that intersectionality with race and rurality complicates these disparities. - The study recommends multilevel, locally tailored interventions to mitigate the adverse effects of social characteristics on cancer outcomes.
## Clinical Analysis & Structured Key Points
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Affiliations Expand ### Affiliations * 1 Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA. * 2 Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, USA. * 3 Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA. * 4 Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA. * 5 Department of Nutrition Sciences, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, USA. * 6 Division of General Internal Medicine and Population Science, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. * PMID: **42812073** * DOI: [ 10.1002/cam4.72333 ](https://doi.org/10.1002/cam4.72333) Item in Clipboard # Intersectionality of Race, Rurality on Persistent Poverty Disparities in Cancer Mortality in Alabama Mackenzie E Fowler et al. Cancer Med. 2026 Oct. Show details Display options Display options Format Abstract PubMed PMID Cancer Med Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Cancer+Med%22%5Bjour%5D&sort=date&sort_order=desc) * [ Search in NLM Catalog ](https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22Cancer+Med%22%5BTitle+Abbreviation%5D) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42812073/) . 2026 Oct;15(10):e72333. doi: 10.1002/cam4.72333. ### Authors [Mackenzie E Fowler](https://pubmed.ncbi.nlm.nih.gov/?term=Fowler+ME&cauthor_id=42812073)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42812073/#short-view-affiliation-1 "Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA."), [Hayden D Reeves](https://pubmed.ncbi.nlm.nih.gov/?term=Reeves+HD&cauthor_id=42812073)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42812073/#short-view-affiliation-2 "Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, USA."), [Suzanne Judd](https://pubmed.ncbi.nlm.nih.gov/?term=Judd+S&cauthor_id=42812073)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42812073/#short-view-affiliation-3 "Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA.")[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42812073/#short-view-affiliation-4 "Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA."), [Kelley Pettee Gabriel](https://pubmed.ncbi.nlm.nih.gov/?term=Gabriel+KP&cauthor_id=42812073)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42812073/#short-view-affiliation-1 "Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA."), [Geetanjali Saini](https://pubmed.ncbi.nlm.nih.gov/?term=Saini+G&cauthor_id=42812073)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42812073/#short-view-affiliation-5 "Department of Nutrition Sciences, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, USA."), [Mahak Bhargava](https://pubmed.ncbi.nlm.nih.gov/?term=Bhargava+M&cauthor_id=42812073)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42812073/#short-view-affiliation-5 "Department of Nutrition Sciences, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, USA."), [Timiya S Nolan](https://pubmed.ncbi.nlm.nih.gov/?term=Nolan+TS&cauthor_id=42812073)[ 6 ](https://pubmed.ncbi.nlm.nih.gov/42812073/#short-view-affiliation-6 "Division of General Internal Medicine and Population Science, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA."), [Ritu Aneja](https://pubmed.ncbi.nlm.nih.gov/?term=Aneja+R&cauthor_id=42812073)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42812073/#short-view-affiliation-5 "Department of Nutrition Sciences, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, USA.") ### Affiliations * 1 Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA. * 2 Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, USA. * 3 Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA. * 4 Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA. * 5 Department of Nutrition Sciences, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, USA. * 6 Division of General Internal Medicine and Population Science, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. * PMID: **42812073** * DOI: [ 10.1002/cam4.72333 ](https://doi.org/10.1002/cam4.72333) Item in Clipboard Cite Display options Display options Format Abstract PubMed PMID Linked Discoveries ## Abstract **Introduction:** Counties in persistent poverty (PP) have higher cancer-related mortality rates. Intersectionality with race and rurality is present; individuals identifying as Black residing in rural PP counties have the highest cancer-related mortality rates. However, heterogeneity exists throughout counties (e.g., demographics). To date, few studies evaluated the effect of small-area PP residence on individual-level survival and intersectionality with race and rurality. **Methods:** This retrospective cohort utilized Alabama Statewide Cancer Registry data of adults with breast, prostate, colorectal, or lung cancer. The exposure was NCI-designated 2010 census tract-level PP (tracts with ≥ 20% population below poverty line for ≥ 30 years) at diagnosis and the outcome was overall survival from date of diagnosis to death or end of follow-up. Associations were estimated via sequential Cox proportional hazards models first with PP as the only predictor then adjusting for demographics (age, race, sex [colorectal, lung]), demographics plus clinical characteristics (stage, subtype [breast], and first course treatment), and finally demographics, clinical characteristics, and social determinants (rurality, insurance status). We also performed a decomposition analysis of the association between PP and survival through race and rurality. **Results:** In the fully adjusted model, living in a PP-tract was associated with higher risk of death among those with breast (hazard ratio [95% CI]: 1.18 [1.09-1.27]), prostate (1.21 [1.11-1.31]), and lung cancer (1.09 [1.05-1.14]) compared to living in a non-PP-tract. Race and rurality were independently associated with higher risk of death across cancers. Individuals identifying as Black residing in a rural PP-tract had the highest magnitude of risk for all cancers. **Conclusions:** Living in a PP-tract is associated with higher risk of death among patients with breast, prostate, and lung cancer in Alabama. This association is complicated by race and rurality. Multilevel interventions tailored to local context may help overcome adverse effects of social characteristics on cancer outcomes. **Keywords:** cancer; intersectionality; persistent poverty; social determinants of health; survival. © 2026 The Author(s). Cancer Medicine published by John Wiley & Sons Ltd. [PubMed Disclaimer](https://pubmed.ncbi.nlm.nih.gov/disclaimer/) ## References 1. 1. American Cancer Society, “Cancer Facts & Figures 2025,” (2025), [https://www.cancer.org/content/dam/cancer‐org/research/cancer‐facts‐and‐...](https://www.cancer.org/content/dam/cancer%E2%80%90org/research/cancer%E2%80%90facts%E2%80%90and%E2%80%90statistics/annual%E2%80%90cancer%E2%80%90facts%E2%80%90and%E2%80%90figures/2025/2025%E2%80%90cancer%E2%80%90facts%E2%80%90and%E2%80%90figures%E2%80%90acs.pdf). 2. 1. American Society for Cancer Research, AACR Cancer Disparities Progress Report 2024 (American Association for Cancer Research, 2024), [https://cancerprogressreport.aacr.org/disparities/cdpr24‐contents/cdpr24...](https://cancerprogressreport.aacr.org/disparities/cdpr24%E2%80%90contents/cdpr24%E2%80%90the%E2%80%90state%E2%80%90of%E2%80%90us%E2%80%90cancer%E2%80%90disparities%E2%80%90in%E2%80%902024/). 3. 1. J. L. Moss, C. N. Pinto, S. Srinivasan, K. A. Cronin, and R. T. Croyle, “Persistent Poverty and Cancer Mortality Rates: An Analysis of County‐Level Poverty Designations,” Cancer Epidemiology, Biomarkers & Prevention 29, no. 10 (2020): 1949–1954, [https://doi.org/10.1158/1055‐9965.Epi‐20‐0007](https://doi.org/10.1158/1055%E2%80%909965.Epi%E2%80%9020%E2%80%900007). 4. 1. J. L. Moss, C. N. Pinto, S. Srinivasan, K. A. Cronin, and R. T. Croyle, “Enduring Cancer Disparities by Persistent Poverty, Rurality, and Race: 1990–1992 to 2014–2018,” Journal of the National Cancer Institute 114, no. 6 (2022): 829–836, . 5. 1. M. H. Tsai, S. S. Coughlin, J. Cortes, and C. A. Thompson, “Intersection of Poverty and Rurality for Early‐Onset Colorectal Cancer Survival,” JAMA Network Open 7, no. 8 (2024): e2430615, . Show all 49 references ## MeSH terms * Adult Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Adult%22%5BMeSH%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Adult) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42812073/) * Aged Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Aged%22%5BMeSH%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Aged) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42812073/) * Alabama / epidemiology Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Alabama%2Fepidemiology%22%5BMeSH%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Alabama) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42812073/) * Female Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Female%22%5BMeSH%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Female) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42812073/) * Humans Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Humans%22%5BMeSH%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Humans) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42812073/) * Male Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Male%22%5BMeSH%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Male) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42812073/) * Middle Aged Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Middle+Aged%22%5BMeSH%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Middle+Aged) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42812073/) * Neoplasms* / epidemiology Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Neoplasms%2Fepidemiology%22%5BMAJR%5D&sort=date&sort_order=desc) * [ Search in MeSH ](h
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