Cancer Burden in Persistent Poverty Areas across the Cancer Continuum: A Scoping Review to Identify Gaps and Opportunities for Future Research.

Introduction
The detrimental impact of place-based poverty on health outcomes (1, 2), including cancer (3–5), is well known. For over a century, public health leaders have documented the influence of poverty on health, linking the characteristics of impoverished areas (e.g., poor air/water quality, lack of education and employment opportunities, lack of access to healthy food) with poor health outcomes for individuals and groups (6, 7). The NCI recognizes poverty as a key driver of cancer disparities and mortality (8, 9). In particular, there is a growing understanding of the influence of long-term place-based poverty, termed persistent poverty, on cancer outcomes (3).
Persistent poverty is an area-level condition wherein a high proportion of the population has lived in poverty for a protracted period of time (4). It is measured as an area where at least 20% of the population has lived below the federal poverty level for 30 years or more (10). Compared with intermittent or short-term high poverty, persistent poverty represents an accumulation of ill health effects for communities and individuals engendered by prolonged economic and resource deprivation (8). Since 2009, the US government has used persistent poverty designations to target resources toward underserved communities (11).
This review used the American Association for Cancer Research (AACR) cancer disparities model (12) to examine the relationship between persistent poverty and outcomes along the cancer continuum, including development, risk reduction, early detection, treatment, survivorship, and mortality. The AACR cancer disparities model draws on social-ecological models of health (13, 14) and the social determinants of health (SDH) framework (1, 2) to demonstrate how systemic inequities, including poverty, racism, and segregation, shape drivers of health (e.g., psychosocial, socioeconomic, and clinical factors), which results in disparities in outcomes along the cancer continuum for marginalized groups. Persistent poverty is the consequence of intersecting systemic inequities, including racial and economic segregation, resource deprivation, localized disinvestment, and geographic isolation (4, 11). Persistent poverty areas are characterized by limited access to healthcare facilities, safe housing, education, employment, healthy food, and public services (11). These areas are overwhelmingly rural and home to large populations of racial and ethnic minorities, particularly Black/African American residents. Though concentrated in the rural South, areas of persistent poverty exist throughout the rural and urban United States. Persistent poverty counties make up 11.2% of all US counties and 15.2% of all rural counties (15). Informed by the AACR cancer disparities model (12), we sought to explore disparities in cancer outcomes by persistent poverty.
It is well established that people living in persistent poverty areas face greater exposure to cancer risk factors, including environmental toxins, high stress, healthy food deserts, and lack of healthcare access (8). Less is known, however, about outcomes across the entire cancer continuum, which encompasses all stages of cancer care, including development, risk reduction, early detection, treatment, survivorship, and mortality (12), and how these outcomes compare with areas without persistent poverty. The goal of this scoping review was to characterize the rapidly growing body of literature on the relationship between persistent poverty and outcomes across the cancer continuum while identifying gaps and opportunities for future research. This review was guided by two research questions:1. What is known about the cancer burden across the cancer continuum in persistent poverty areas in the United States?

2. What gaps exist in the literature about the cancer burden across the cancer continuum in persistent poverty areas in the United States?

Materials and Methods
We conducted a scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (16). Scoping reviews are appropriate when researchers are mapping the extent and nature of the literature and determining possible gaps (16, 17). Scoping reviews do not involve human subjects and thus do not require ethics approval or Institutional Review Board review. The goal was to identify articles that used the concept of persistent poverty to frame the geographic area or study population and assessed the impact of exposure to persistent poverty on a cancer-related outcome, including development, risk reduction, early detection, treatment, survivorship, and mortality.

Literature search
The search strategy aimed to identify articles that examined the relationship between persistent poverty and cancer-related outcomes. A research librarian (K. Strahan) formulated and conducted the searches in the following databases in February 2024: CINAHL, Embase, PubMed MEDLINE, and Web of Science. Search terms were tailored for each database using controlled vocabulary where applicable (i.e., Medical Subject Headings) and keywords related to persistent poverty and cancer terminology (see Supplementary Methods S1 for the search strategy for each database). A hand search was performed in August 2024 that added five articles to the full-text review and extraction process. The full search strategy for each database can be found in Supplementary Methods S1. The multidatabase search yielded 4,857 results that the medical librarian uploaded into Covidence, a review management system. These results are inclusive of an updated search that was conducted in July 2025 that yielded an additional 70 results. Covidence identified 1,940 duplicates, and there were 19 duplicates identified by hand. A total of 2,898 abstracts were screened to determine eligibility. Each citation was reviewed independently by two study team members against predefined inclusion and exclusion criteria (Fig. 1).

Inclusion and exclusion
Peer-reviewed journal articles published in English between January 1, 2009 (the first year the persistent poverty designation was used in policy implementation), and July 9, 2025, were included if they were conducted in the United States, included empirical data, and described a cancer-related outcome at any stage along the cancer continuum in a persistent poverty area or compared a cancer-related outcome in persistent poverty area(s) with other places. We excluded studies that were dissertations, preprints, reviews, reports, commentaries, or abstracts.

Article screening, selection, and data extraction
Blinded coauthors (E. Hallgren, P. DelNero, M. Schootman, B.C. Amick, K. Owsley, J.L. Allen) used Covidence review software to independently check the titles and abstracts based on the inclusion and exclusion criteria. Two authors independently reviewed and voted to include or exclude each abstract, with conflicts resolved by a third author. This was followed by a full-text review of 512 selected articles. Each full-text publication was independently reviewed by two reviewers; conflicts were resolved by a third team member.
Thirty-five articles were retained for data extraction. The study team collaboratively developed a standardized data extraction template in Covidence. Each article’s data were extracted by one team member and checked by a separate team member. The information recorded included study aims, study population, definition of persistent poverty, geographic measurement of persistent poverty (e.g., county/census tract), geographic study setting, cancer site(s) studied, outcome(s) assessed along the cancer continuum, and main findings related to persistent poverty. We also recorded each article’s study design, data source(s), inclusion of a community advisory board or community-engaged research, and funding. Because this was a scoping review, we did not assess the quality of evidence of the included articles (16).

Results

Characteristics of included articles

Table 1 provides an overview of the included articles. Articles were published between 2011 and 2025, with the vast majority (94%) published between 2020 and 2025 (Fig. 2). Overall, studies aimed to assess the association between persistent poverty exposure and one or more cancer-related outcomes, with some also examining the influence of factors including rurality, race or ethnicity, and residential segregation. Study populations varied from samples of patients diagnosed with a range of cancers, patients diagnosed with a single cancer type, and samples of adults in particular geographic locations. Sample sizes varied from less than 1,000 patients in studies using primary data to analyses of the entire US population using population-based registries.
Most studies used the US Department of Agriculture Economic Research Service (USDA ERS) definition of persistent poverty as an area where at least 20% of the population has lived below the federal poverty level for 30 years or more (10). Twenty-two studies (62.9%) measured persistent poverty at the county level, and nine studies (25.7%) used census tracts (Table 2). Twenty-two articles (62.9%) analyzed data representing the entire United States, 11 focused on a single state (31.4%), and two focused on a single neighborhood (5.7%; Table 2).

Study design, data source(s), and funding sources
Thirty studies (85.7%) reported on observational analyses using large secondary datasets. Of these studies, most analyzed data from Surveillance, Epidemiology, and End Results (SEER) or SEER–Medicare registries. Other studies used the Centers for Disease Control and Prevention’s databases (e.g., US Cancer Statistics, Behavioral Risk Factor Surveillance System). Four studies (11.4%) reported on observational primary data (survey and qualitative) and used community-engaged research or involved a community advisory board; one study (2.9%) evaluated an intervention (Table 2). Twenty-one studies (60%) cited a government source of funding (e.g., NIH, Centers for Disease Control and Prevention, Federal Office of Rural Health Policy, state grants).

Primary outcomes across the cancer continuum
Of the 35 included articles, 25 (71.4%) addressed a single outcome on the cancer continuum, either development (including incidence and stage at diagnosis), risk reduction, early detection, treatment, survivorship (including palliative end-of-life care), or mortality. Cancer mortality was the most frequently studied outcome among included studies. Fourteen studies examined two or more cancer sites, and the remainder focused on a single cancer site, including breast, colorectal, gastric/gastrointestinal, hepatopancreaticobiliary, liver, lung, melanoma, oral/pharyngeal, and prostate (Fig. 3A). Ten articles (28.6%) examined more than one cancer continuum outcome (Fig. 3B).

Development (incidence and stage at diagnosis)
With respect to cancer incidence rates, studies found that persistent poverty was associated with higher incidence rates for several cancer sites, including lung/bronchus (18), oral and pharyngeal (19), and early-onset gastric cancer (20). Bhattacharya and colleagues (21) found higher incidence rates in persistent poverty census tracts for multiple cancer sites (cervical, colorectal, liver, lung/bronchus, oropharyngeal, and stomach), but not for breast and prostate cancer. Conversely, persistent poverty overlapped with lower-than-average incidence rates of melanoma in Texas (22). Incidence rates in persistent poverty areas often increased with rurality; in one study, lung cancer incidence was highest in rural, persistent poverty counties (18).
Overall, included studies found that persistent poverty was associated with advanced-stage cancer diagnosis. Studies examining stage at diagnosis for oral and pharyngeal (19), breast (23), non–small cell lung cancer (NSCLC; ref. 24), and multiple cancer sites (21) all found that persistent poverty increased the likelihood of late-stage diagnosis. Rurality and race intersected with persistent poverty to influence stage at diagnosis outcomes. Bhattacharya and colleagues (21) found that late-stage diagnosis rates for liver cancer in persistent poverty census tracts increased with increasing rurality. White patients in persistent poverty areas were more likely to present with early-stage disease than Black patients in areas without high poverty, highlighting the higher likelihood of advanced-stage diagnosis for Black individuals regardless of area-level socioeconomic status (25).

Risk reduction
Two studies addressed smoking; one study (18) found that smoking rates were highest in counties that were both rural and in persistent poverty, whereas another found that smokers in persistent poverty counties who received financial incentives in addition to cessation coaching calls reported greater smoking abstinence and treatment engagement than those who did not (26). A qualitative study (27) found that transportation, healthcare costs, limited availability of providers and services, and patient discomfort with cancer were identified as barriers to cancer prevention behaviors by clinic staff/providers, whereas community health workers and local community health events were facilitators.

Early detection
Included studies consistently found that living in a persistent poverty area was associated with worse access to and lower rates of common cancer screenings. Breast and colorectal cancer screenings were the most common studied. Living in a persistent poverty area was associated with lower screening rates for breast cancer in North Carolina (28) and cervical and colorectal cancer in Pennsylvania (29). Rurality intersected with persistent poverty, with one study finding lower reported screening rates for cervical, colorectal, and breast cancer in rural persistent poverty counties compared with other rural counties and urban counties (30). Both adult and child persistent poverty were significantly associated with a decreased likelihood of an American Indian and Alaska Native tribal headquarters being within 200 miles of lung cancer and CT colonography screening centers; no association was found for mammography screening proximity (31).

Treatment
Overall, persistent poverty was associated with worse treatment outcomes. One study (32) observed that residence in a persistent poverty census tract was associated with poorer breast cancer tumor characteristics, a higher likelihood of mastectomy (vs. lumpectomy), and a lower likelihood of breast reconstruction (32). Another study (24) found that patients with NSCLC and breast cancer living in persistent poverty areas were significantly less likely to receive surgical resection for localized disease.

Survivorship
Cancer survivors in a persistent poverty neighborhood frequently had complex health issues and comorbidities (e.g., obesity) coexisting with their status as cancer survivors (33). Patients with gastrointestinal cancer who are living in persistent poverty counties had higher odds of filling an opioid prescription near their end of life but received lower daily opioid doses compared with patients in counties that never experienced high poverty (34).

Mortality
Overall, cancer mortality was significantly higher in persistent poverty areas. Persistent poverty residence was associated with higher cancer mortality rates for patients with breast cancer (24, 32), hepatopancreaticobiliary cancer (25, 35), melanoma (36), colorectal cancer (24, 37–40), NSCLC (24), liver cancer (41, 42), lung cancer (18), and oral and pharyngeal cancers (19). Persistent poverty counties experienced higher cancer mortality rates than nonpersistent poverty counties, both overall and for multiple individual cancer sites (43), and disparities in cancer mortality rates by persistent poverty endured over a time period of approximately 25 years (44).
Differences in cancer mortality risk by racial group were observed. One study found that White patients living in persistent poverty areas had an increased risk of colorectal cancer death compared with their counterparts in nonpersistent poverty areas, but the same did not hold for Black patients (37). In a study of the entire United States examining all cancer types, Black residents of rural, persistent poverty counties had the highest cancer mortality rates overall and for colorectal, oropharyngeal, breast, cervical, and prostate cancers (44). Urban–rural differences were observed, with one study finding that patients with oral and pharyngeal cancers in urban persistent poverty areas had higher rates of both all-cause and cancer-specific mortality than those in rural persistent poverty areas (19).

Discussion
The goal of this scoping review was to characterize the rapidly growing body of literature on the relationship between persistent poverty and outcomes across the cancer continuum. We aimed to assess the current scope of literature on this topic and identify gaps and opportunities for future research. Informed by the AACR cancer disparities model (12), we also sought to assess cancer disparities by persistent poverty. Based on the findings of the 35 included articles, there are significant disparities in outcomes along the cancer continuum due to persistent poverty. Residents of persistent poverty areas face higher cancer incidence and advanced-stage diagnosis rates, higher rates of smoking and barriers to cancer prevention, lower rates of cancer screening, worse treatment outcomes, higher mortality rates, poverty-related survivorship challenges, and disparities in access to end-of-life care. Persistent poverty intersects with race and rurality in several studies, with Black/African American and rural residents often, but not always, experiencing worse outcomes.
The AACR cancer disparities model proposes that systemic inequities, including poverty and segregation, shape drivers of health, which leads to cancer health disparities for marginalized groups, including racial and ethnic minorities, rural residents, and those living in persistent poverty. The included studies in this scoping review clearly show that residents of persistent poverty areas, who are disproportionately Black/African American and rural, face significant and enduring disparities along the cancer continuum.

Cancer mortality, persistent poverty, and race
Included studies showed cancer mortality rates were consistently higher in persistent poverty areas than in nonpersistent poverty areas, with disparities disproportionately affecting Black/African American residents. Other research has similarly found that high area-level deprivation is correlated with higher cancer mortality (45–47). However, extant research suggests the influence of area-level deprivation on cancer mortality may differ between racial groups. Recent work found that neighborhood disadvantage contributes to higher breast cancer mortality for White women, but the association is less clear for Black women (48, 49), suggesting that other factors may more directly link Black racial identity to higher breast cancer mortality. In this review, Tsai and colleagues found that Black residents had higher colorectal cancer mortality than White patients in regions of Georgia. However, although White patients in persistent poverty areas had a higher colorectal cancer mortality risk than their counterparts in nonpersistent poverty areas, this difference was not observed for Black patients. This suggests that area-level deprivation may not be driving the higher colorectal cancer mortality risk for Black patients. At the same time, Moss and colleagues found that Black residents of rural, persistent poverty counties had the highest cancer mortality rates of all groups examined, overall and for several individual cancer sites, suggesting a compounding effect of rural residence, persistent poverty, and Black racial identity. Future research should consider how area-level deprivation, rurality, racial identity, and cancer type interact in different settings to influence cancer mortality.

Measurement and definition of persistent poverty
Most articles used a county-level measure of persistent poverty, which has been in use by the USDA ERS since 1985 (11). Recently, the NCI, with support from the USDA ERS, added census tracts to SEER’s persistent poverty measures (21). The county-level measurement may obscure smaller areas of concentrated and entrenched high poverty, particularly city neighborhoods, often characterized by racial segregation and economic divestment in large metropolitan areas. Subcounty-level measurements (i.e., census tracts) of persistent poverty may allow for more targeted research and interventions. The time points used to define an area as experiencing persistent poverty varied between studies, particularly those using county-level measurement. Studies should clearly state the time points used to define persistent poverty areas and use the most recently available data whenever possible.

Gaps and opportunities for future research
There are several areas to consider for future research. Future work should examine policy- and institutional-level interventions to address the root causes that keep areas in persistent poverty, such as racial and economic segregation, resource deprivation, local disinvestment, and lack of education and employment opportunities. Interventions to address these structural-level inequities and drivers of poor health outcomes will require organized and empowered community members and political will (50–52). Such efforts will rely on building partnerships between healthcare centers/providers, community groups, and policymakers aimed at addressing SDH such as food, housing, transportation, and job insecurity. For example, innovative approaches to create access to affordable, healthy food within food deserts, such as community-supported enterprises, municipal-run grocery stores, and healthcare partnerships with local markets, have shown promise in both impoverished rural and urban settings (53–56); this is an area ripe for intervention research in persistent poverty areas.
Relatedly, future work should better engage with theoretical frameworks to identify the structural and social determinants of cancer disparities for residents in persistent poverty areas. Conceptual frameworks outlining how social and environmental contexts influence disease risk and health outcomes (e.g., SDH, social-ecological models, fundamental cause theory, health disparities frameworks; refs. 2, 13, 57–59) are essential for identifying the mechanisms linking persistent poverty exposure to poor cancer outcomes. These frameworks would also highlight the need for multilevel interventions.
Future studies should examine the structural factors within healthcare systems that contribute to poorer cancer outcomes for individuals in persistent poverty areas, such as insurance coverage and rural provider availability. This research is particularly salient with the increasing number of rural hospital closures and loss of essential healthcare services (60), which may exacerbate preexisting disparities in these areas. Additionally, studies might explore how state and federal policies, such as state Medicaid expansion and community health worker reimbursement, differentially affect those living in persistent poverty areas.
No studies in this review assessed patient quality of life as an outcome. Research shows area-level deprivation is related to worse psychologic well-being and quality of life for patients following cancer treatment (61, 62). Quality of life is a key patient-reported outcome and should be explored among both patients and longer-term survivors in persistent poverty areas.
Intervention research is urgently needed to understand how to mitigate cancer disparities in persistent poverty areas. Current initiatives are evaluating a range of interventions from survivorship healthy behavior programs to guaranteed basic income programs (63). Additional research should evaluate the effectiveness of interventions aimed at improving access to cancer screening and treatment, such as community health worker programs, telemedicine, transportation assistance, and financial support for treatment-related costs.

Strengths and limitations
This review has several strengths. We characterized a rapidly growing body of research that has the potential to influence cancer prevention and control efforts in persistent poverty areas, which face a disproportionate cancer burden. To ensure rigor, we employed several strategies that are recommended as best practices for scoping reviews, including regular team meetings, defining terms, working with a research librarian, double-screening abstracts and full texts, pilot testing the data extraction template, and having two members independently extract article data, with a consensus check by a third team member (64).
There are limitations to this review. It is possible that our search terms resulted in missing some articles, and our search criteria excluded conference abstracts and pieces published in the “gray literature” that have not undergone peer review. Our literature search may have omitted studies that were conducted in persistent poverty areas without explicitly using the concept of persistent poverty to define the geographic area or study population (e.g., Appalachia or the Mississippi Delta). Likewise, studies of poverty or area deprivation were excluded if they did not specifically define the duration of poverty. A full synthesis of area-level socioeconomic determinants of cancer health outcomes was beyond the scope of this review.

Conclusion
The findings of this review demonstrate a disproportionate cancer burden for residents of persistent poverty areas, with disparities in outcomes observed across the cancer continuum. The NCI has described poverty as a carcinogen because of its role in exacerbating cancer disparities and mortality (3). Future research should focus on structural inequities and social drivers of disparate cancer outcomes in persistent poverty areas and on designing interventions and policies to eliminate persistent poverty and promote cancer health equity for communities across the United States.

Supplementary Material
Supplementary MethodsSupplementary Methods shows the search strategy for each database (e.g., query terms, results).