Lung cancer is falling everywhere, slowest for rural women

Lung cancer is the leading cause of cancer death in the United States —
148,869 deaths in 2016 — and **most lung cancers can be attributed to
modifiable exposures**: tobacco, secondhand smoke, radon, asbestos.

Incidence is falling. The useful question is how fast, and for whom.

Four rates of decline

Annual percent change, 2007–2016:

Every number is negative. That is the good news and the thing that hides the
problem: a gap widens whenever two lines fall at different speeds, and
−0.5% against −2.9% is nearly six times.

Men's rates fell in every age group in both kinds of county. The largest
declines were among men aged 45–54 in metropolitan counties (−5.2%) and
35–44 in non-metropolitan counties (−5.0%) — the younger the cohort, the
steeper the fall, which is what a generation that took up smoking less looks
like arriving in the data.

The narrowing that is not good news

The sexes converged — because men's rate fell 17 points while women's fell
three. **The highest overall incidence in the study was still among men in
non-metropolitan counties**, and the slowest improvement was among the women
beside them.

Why the rural line is flatter

From the 2017 National Health Interview Survey, comparing non-metropolitan
with metropolitan adults:

Nearly twice the smoking, fewer attempts, and **just over half the success
rate among those who try.** The third row is the one that matters most for
policy: the difference is not only in who starts but in who is able to stop,
and that is about the help available.

**Access to preventive services can be more limited in non-metropolitan
areas**, and **rural areas may be less likely to have strong smoke-free laws or
barrier-free access to cessation programmes.**

What is recommended, and what is being tried

The prevention list is not new: **screen for tobacco dependence, promote
cessation, comprehensive smoke-free laws, test every home for radon and fix
high levels, reduce asbestos exposure.** The US Preventive Services Task Force
asks clinicians to screen every adult for tobacco use at each visit and
refer or provide behavioural and pharmacological cessation support.
Screening for lung cancer is recommended for adults at high risk by age and
smoking history — and is itself an opening to promote quitting.

Two concrete adaptations from CDC's National Comprehensive Cancer Control
Program:

• Maine identified which lung cancer screening facilities exist in
  non-metropolitan and metropolitan areas, and is working on the barriers that
  map revealed — capacity before campaigns
• Patient navigators and community health workers to address financial
  hardship, inadequate insurance and lack of transport. CDC and the
  Appalachian Regional Commission have funded research into how navigation
  helps cancer survivors in non-metropolitan areas reach care

**Accelerating these, particularly for women living in non-metropolitan
areas, is what would close the gap** — the group whose line is nearly flat.

Source: Centers for Disease Control and Prevention, MMWR.