Association of rurality status with all-cause and cancer-specific survival: a systematic review and meta-analysis adjusting for clinical factors, demographics, and geographical remoteness.

The association of rurality status with cancer survival has not been consistently reported. In people diagnosed with cancer, this review aims to determine the association of rural and remote living with survival as compared to urban living, and to determine the modifying effects of geographical, medical, demographic, and socioeconomic factors on cancer survival. A systematic review with meta-analysis and meta-regression was conducted, searching four databases in August 2024. Observational cohort studies were eligible if they reported all-cause or cancer-specific survival according to rurality status in Organisation for Economic Co-operation and Development (OECD) countries. All ages, sexes, and cancer types were eligible. Risk of bias was assessed using the Newcastle-Ottawa Scale and pooled models were evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE). Meta-analyses and meta-regressions were performed using R statistical environment. 37 studies reporting on 110 comparator groups were included. People with cancer in rural areas were at a survival disadvantage compared to people in urban areas, with 15% lower odds of all-cause survival (OR 0.85 [95% CI 0.74, 0.97]) and 10% lower odds of cancer-specific survival (OR: 0.90 [95% CI 0.86, 0.95]). Cancer type and degree of geographical remoteness were consistent modifiers of survival in univariable and multivariable regression. Increasing degree of geographical remoteness was associated with lower odds of all-cause survival (OR 0.28 [95% CI 0.12-0.67]). People living in rural areas diagnosed with cancer have lower odds of all-cause and cancer-specific survival which worsened with increasing geographical remoteness. Type of cancer was consistently found to be a modifying factor of cancer survival. Increased recognition of people living in rural areas as a priority population group in health and cancer policies is needed to improve cancer equity. Funding: Commonwealth of Australia's Medical Research Future Fund (MRF2030313).