RURAL hepatocellular carcinoma (HCC) incidence in the USA increased between 2001 and 2022, while rates declined in urban areas, according to a large population-based study analysing more than 264,000 cases of HCC.
HCC accounts for around 90% of liver cancers and is linked to chronic viral hepatitis, alcohol-related liver disease, obesity, diabetes, and metabolic dysfunction-associated steatohepatitis (MASH). Researchers said the findings point to widening geographic disparities in liver cancer prevention, screening, and specialist care.
Diverging HCC Trends Emerge Across Regions
The study analysed 264,633 HCC cases, of which 77.0% occurred in men and 86.6% in urban areas. Among men, HCC incidence was 4.5 per 100,000 people in rural counties compared with 5.8 per 100,000 in urban counties. Among women, rates were 1.2 and 1.5 per 100,000 respectively.
Despite lower absolute incidence rates in rural populations, HCC incidence increased annually by 1.1% among men from 2007 to 2022 and by 1.7% among women from 2001 to 2022. By contrast, urban incidence rates declined by 1.4% per year among men and 1.0% among women over similar periods.
Incidence-based mortality followed the same divide. Rural mortality rates rose by 1.2% annually among men and remained stable among women, whereas urban mortality fell by 1.4% per year in men and 1.0% in women.
The findings suggest that improvements in HCC prevention and management have not been distributed evenly across geographic regions, with rural populations experiencing worsening incidence and mortality trends despite declines in urban areas.
Changing Liver Disease Risks May Be Reshaping HCC Burden
Researchers suggested the decline in urban HCC rates may reflect long-term reductions in viral hepatitis-related liver disease due to improved prevention, screening, and treatment.
However, the underlying drivers of HCC appear to be shifting. MASH, obesity, diabetes, and ALD are becoming increasingly important contributors to liver cancer risk and are more prevalent in rural populations.
National surveillance data cited in the study showed that obesity affects approximately 34% of adults in rural areas versus 29% in urban settings, while diabetes prevalence is around 14% compared with 11%.
The study also identified a 2% annual increase in advanced-stage HCC incidence in rural counties. Investigators noted that rural residents often face reduced access to hepatologists, longer travel distances to tertiary centres, and lower surveillance rates for cirrhosis and HCC, all of which may delay diagnosis.
Barriers to Care Remain a Key Concern
Several limitations were noted. The researchers excluded 2020 because of potential COVID-19 effects on HCC incidence, although pandemic-related disruption may have continued into 2021 and 2022. Reporting delays and improvements in cancer staging data over time may also have influenced some trends.
The findings support the need for targeted prevention strategies and improved access to early detection and specialist care in rural communities.
Reference
Damgacioglu H et al. Rural-urban disparities in hepatocellular carcinoma incidence and mortality. JAMA Net Open. 2026;DOI:10.1001/jamanetworkopen.2026.12323.
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