Cancer deaths in the United States fell by 34% between 1991 and 2022, an improvement credited to advances in screening, prevention, and treatment — but new research shows those gains have not been shared equally across the country. A study examining cancer mortality across nearly 3,000 U.S. counties found that large, wealthy urban centres, particularly along the coasts, drove much of the improvement, with some Manhattan and San Francisco Bay Area counties recording declines exceeding 47%, while rural counties in states such as Mississippi, Arkansas, and West Virginia saw far smaller reductions of 20–24%, and around 458 rural counties saw cancer deaths actually rise. The disparity is linked to income levels, weaker tobacco control policies in rural areas, and unequal access to advanced treatments, with researchers warning that the U.S. has become more effective at developing cancer innovations than at distributing them equitably.