Rural-urban disparities in high‑risk non-muscle‑invasive bladder cancer: lessons from the Canadian Bladder Cancer Information System
Makito Miyake
Keywords: Rural health; bladder cancer (BCa); non-muscle‑invasive bladder cancer (NMIBC); health disparities; quality of care
Submitted Apr 29, 2026. Accepted for publication Jun 18, 2026. Published online Jul 22, 2026.
doi: 10.21037/tau-2026-0412
Introduction
According to the updated global statistics, bladder cancer (BCa) is the ninth most common malignancy worldwide with an estimated 614,298 new cases of BCa and 220,596 mortalities occurred in 2022 (1). Incidence and mortality rates varied largely across regions and countries, with the highest rates reported in European countries and increased rates were observed in North America, Northern Africa, and Western Asia. In addition, Eastern Asia reported the highest absolute numbers of patients with BCa due to its large population. By 2040, the annual number of new BCa cases and deaths is projected to rise to 991,000 (a 72.8% increase) and 397,000 (an 86.6% increase), respectively (2). Among non-muscle-invasive bladder cancer (NMIBC), approximately half of patients are categorized in high-risk NMIBC (HR-NMIBC) defined as high-grade (HG) urothelial carcinoma (UC) with high-risk features including carcinoma in situ (CIS) of the bladder or prostatic urethra, T1, large tumor (>3 cm), multifocal, certain histopathologic subtypes and lymphovascular invasion on transurethral resection of bladder tumor (TURBT) (3). HR-NMIBC requires repeat transurethral resection (re-TUR), frequent surveillance, and adjuvant intravesical therapy such as intravesical Bacille de Calmette et Guérin (BCG) (4).
Previous epidemiologic studies have demonstrated that patients with BCa living in rural area have higher overall mortality and cancer-specific mortality (4-7), potentially reflecting higher rates of smoking habits and overall poorer health in rural patients. Rural patients may face additional barriers to accessing health care service due to their geographic location such as longer wait times, travel burden, delays in diagnosis, and limited access to contemporary treatment protocols (8). The effect of rurality on other quality benchmarks, such as rate of re-TUR and post-TUR intravesical treatment, remains unclear (7,9). A possible explanation for the disparity in oncologic outcomes might be disparate rates of treatments effective in reducing rates of bladder recurrence and progression (10-13). To date, limited data are available to evaluate the impact of rurality on the management and outcomes in patients with NMIBC.
Rurality as a determinant of BCa outcomes in the Canadian landscape
The study reported by Chung et al. provides a timely and methodologically rigorous examination of how rurality affects the management and outcomes of HR-NMIBC by leveraging a national, prospectively maintained cohort (14). By using the Canadian Bladder Cancer Information System (CBCIS) including 2,838 patients with high-risk NMIBC, in which 71% were urban and 30% were rural. Overall, the authors demonstrate rural patients were significantly less likely to meet all quality-of-care benchmarks, for example, 40% of rural and 57% of urban patients underwent guideline-compliant surveillance cystoscopy (P=0.04). Second TUR was performed within 90 days for high-grade T1 disease in 29% of urban and 23% of rural patients (P=0.04). Rural patients were less likely than urban patients to receive induction BCG (52% vs. 69%, P<0.0001). As a result, rural patients experience significantly worse progression‑free survival (PFS).
The CBCIS database is a National, prospective, multi‑institutional cohort, which captures granular clinical data—including pathology, intravesical therapy, and surveillance patterns—allowing for precise evaluation of quality‑of‑care metrics. Interestingly, the Statistics Canada Remoteness Index based on a modern, validated measure of rurality incorporates travel time, transportation networks, and access to service hubs—superior to simple population‑based definitions. The rigorous assessment provided clear differences in quality benchmarks: rural patients were (I) less likely to undergo restaging TURBT (23% vs. 29%; P=0.04); (II) less likely to receive induction BCG (52% vs. 69%; P<0.0001); (III) less likely to receive maintenance BCG; and (IV) less likely to undergo guideline‑compliant cystoscopy (40% vs. 57%; P=0.004). These deficits are clinically meaningful, given the central role of TURBT quality, BCG therapy, and surveillance intensity in preventing progression. In addition, 5-year PFS was significantly lower among rural patients (80% vs. 85%; P=0.048); however, overall survival (OS) did not differ significantly—probably due to limited follow‑up and the long natural history of NMIBC.
Interpreting the findings of CBCIS study
The CBCIS results reinforce a central theme: geography influences outcomes primarily through access and care‑process differences, not biology. First, rural patients have travel burden to receive medical service. For example, BCG therapy requires weekly visits for induction and prolonged maintenance phase. For patients living hundreds of kilometers from tertiary centers, adherence becomes challenging. Second, there is a limitation in operating room access. Re-TUR is timesensitive and most of smaller hospitals may have limited operating room capacity, contributing to lower re-TUR rates. Third, poor surveillance infrastructure, for example, frequent cystoscopy requires flexible scheduling and local endoscopic capacity—often limited in rural regions. The risk-adapted follow-up approach in the clinical guidelines describe that patients with high-risk NMIBC should undergo cystoscopy and urinary cytology every 3 months in the first 2 years, every 6 months in the next 3 years, and every year after 5 years (15). Culpan et al. demonstrated that a cystoscopy delay of more than 90 days increased the probability of progression by 6.7-fold in patients followed up during the coronavirus disease of the 2019 pandemic (June–September 2020) (16). Another observational, retrospective cohort study from Palestine showed that a group with low compliance to a standardized surveillance protocol in NMIBC is associated with poor outcomes in comparison to a compliant group (17). Based on the evidences, non-compliance to the clinical practice guideline would be a potential driver to worse outcomes. Lastly, the global BCG shortage disproportionately affected rural patients, highlighting how supplychain disruptions can exacerbate geographic inequities (18).
The CBCIS study is notable for providing high‑quality, contemporary Canadian data in a universal health‑care system—allowing geography to be examined with fewer confounding effects from insurance coverage or financial barriers. Potential limitations in the CBCIS study includes (I) follow‑up may be insufficient to detect OS differences; (II) limited socioeconomic data; (III) indications for cystectomy not fully captured; and (IV) potential selection bias toward academic centers.
Rural-urban disparities across major BCa studies
The association between rural residence and inferior bladder‑cancer outcomes has been documented in multiple settings. Table 1 lists disparities in survival and incidence of BCa by urban versus rural residence (5,14,19,20). The study using Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2008 in Utah state demonstrated that cancer patients (all types of cancer) living in rural counties were more likely to be older and rural residents had a 5-year relative survival that was 5.2% lower than metropolitan residents and a 10% increase in risk of death after adjustment for multiple factors (19). However, no large difference in 5-year OS rates of BCa patients between rural residence (74.4%) and urban residence. Another SEER database from 2004 to 2016 in USA analyzed 222,330 patients with BCa, consisting of 3,496 (1.6%) resided in rural area, 25,462 (11.5%) in urban clusters and 193,372 (87%) in urbanized areas (5). Age, tumor stage, radical cystectomy rates or chemotherapy use were comparable between RA, UC and UA. Rural area was associated with highest 10-year other cause mortality followed by urban clusters and urbanized areas (30.9% vs. 27.7% vs. 25.6%, P<0.01). Cancer-specific mortality was marginally higher in rural area or urban clusters vs. urbanized areas (20.0% vs. 20.1% vs. 18.8%, P=0.01). The epidemiologic study using the National Cancer Database (NCDB) from 2004 to 2015 in USA demonstrated (I) rural area residence was significantly associated with poor OS compared to urban area; (II) no difference in the likelihood of receiving radical cystectomy and chemoradiotherapy among residential areas; (III) among patients who underwent radical cystectomy; individuals living in rural area were less likely to receive neoadjuvant chemotherapy and adequate lymph node dissection, and had a higher probability of positive surgical margin than those living in urban areas; and (IV) for those who received chemoradiotherapy; individuals living in Metro areas were more likely to receive concomitant systemic therapy compared to urban-rural remote to metro area (20).
Table 1
| First author, year of publication | Citation | Source | Residency | Total | Patients with bladder cancer (%) | Stage | Survival | Main findings |
|---|---|---|---|---|---|---|---|---|
| Hashibe 2018 | (19) | SEER database from 2004 to 2008 in Utah state | Urban metropolitan | 29,451 | 995 (incidence rate, 3.4%) | Any stage | 5-year OS rate (95% CI): 77.5% (73.5–81.0%) | (I) Cancer patients living in rural counties were more likely to be older. (II) Rural residents had a 5-year relative survival that was 5.2% lower than metropolitan residents and a 10% increase in risk of death after adjustment for multiple factors. (III) The cancer incidence rates in rural counties were lower by 11.9 per 100,000 per year (449.2 in rural counties vs. 461.1 in metropolitan counties). (IV) Cancer patients living in rural counties of Utah had different demographic characteristics as well as differences in incidence and survival rates |
| Rural | 4,295 | 163 (incidence rate, 3.8%) | Any stage | 5-year OS rate (95% CI): 74.4% (63.7–82.3%) | ||||
| Deuker 2021 | (5) | SEER database from 2004 to 2016 in USA | Urban metropolitan | – | 25,462 | NMIBC: 19,729 (76%); MIBC: 5,733 (24%) | 10-year CSM: 20.1% | (I) Of 222,330 patients, 3,496 (1.6%) resided in rural area, 25,462 (11.5%) in urban clusters and 193,372 (87%) in urbanized areas. (II) Age, tumor stage, radical cystectomy rates or chemotherapy use were comparable between RA, UC and UA. (III) Rural area was associated with highest 10-year other cause mortality followed by urban clusters and urbanized areas (30.9% vs. 27.7% vs. 25.6%, P<0.01). (IV) CSM was marginally higher in rural area or urban clusters vs. urbanized areas (20.0% vs. 20.1% vs. 18.8%, P=0.01) |
| Urbanized areas | – | 193,372 | NMIBC: 151,464 (78%); MIBC: 41,908 (22%) | 10-year CSM: 18.8% | ||||
| Rural | – | 3,496 | NMIBC: 2,697 (77%); MIBC: 799 (23%) | 10-year CSM: 20.0% | ||||
| Dursun 2023 | (20) | The NCDB from 2004 to 2015 in USA | Urban metropolitan | – | 58,874 (83%) | Localized MIBC | 5-year OS rate (95% CI): 30% (30.6–31.5%); 10-year OS rate (95% CI): 22.2% (21.7–22.7%) | (I) Rural area residence was significantly associated with poor OS compared to urban area. (II) No difference in the likelihood of receiving radical cystectomy and chemoradiotherapy among residential areas. (III) Among patients who underwent radical cystectomy; individuals living in rural area were less likely to receive neoadjuvant chemotherapy and adequate lymph node dissection, and had a higher probability of positive surgical margin than those living in urban areas. (IV) For those who received chemoradiotherapy; individuals living in metro areas were more likely to receive concomitant systemic therapy compared to urban-rural remote to metro area |
| Urban-rural adjacent | – | 8,534 (11.9%) | Localized MIBC | 5-year OS rates (95% CI): 29.7% (28.6–30.8%); 10-year OS rates (95% CI): 17% (15.3–18.2%) | ||||
| Urban-rural remote to metro area | – | 3,987 (5.6%) | Localized MIBC | 5-year OS rate (95% CI): 28.4% (26.7–30.0%); 10-year OS rate (95% CI): 16.8% (4.9–18.9%) | ||||
| Chung 2026 | (14) | CBCIS from 2015 to 2024 | Urban metropolitan | 29,451 | 995 (incidence rate, 3.4%) | Any stage | 5-year OS rate (95% CI): 77.5% (73.5–81.0%) | (I) Rural patients were less likely to undergo restaging TURBT (23% vs. 29%). (II) Rural patients were less likely to receive induction BCG (52% vs. 69%) and maintenance BCG. (III) Rural patients were less likely to undergo cystoscopy (40% vs. 57%). (IV) 5-year PFS was significantly lower among rural patients (80% vs. 85%); history of NMIBC |
| Rural | 4,295 | 163 (incidence rate, 3.8%) | Any stage | 5-year OS rate (95% CI): 74.4% (63.7–82.3%) |
BCG, Bacille de Calmette et Guérin; CI, confidence interval CBCIS; CSM, cancer-specific mortality; MIBC, muscle invasive bladder cancer; NCDB, National Cancer Database; NMIBC, non-muscle invasive bladder cancer; OS, overall survival; PFS, progression‑free survival; RA, rural areas; SEER, Surveillance; TURBT, transurethral resection of bladder tumor; UA, urbanized areas; UC, urban clusters.
In 2008, a comprehensive literature review of rural-urban health status differentials within Australia, New Zealand, Canada, the USA, the UK, and a variety of other western European countries was performed to reveal the differences in life expectancy and cause-specific morbidity and mortality (8). The authors concluded when controlling for major risk determinants, rurality does not necessarily lead to rural-urban disparities, but may exacerbate the effects of socio-economic disadvantage, ethnicity, poorer service availability, higher levels of personal risk and more hazardous environmental, occupational and transportation conditions.
Conclusions
During the 1990s, ‘rural health’ emerged as a significant concern requiring special attention by developed world governments (8,21). Geographic inequities in cancer care have long been recognized across high‑income countries. Rural residence—whether defined by population density, travel distance, or composite remoteness indices—has repeatedly been associated with inferior outcomes for several malignancies. BCa is no exception. Yet the mechanisms underlying these disparities remain incompletely understood, and future research should incorporate more granular patient‑level risk factors, including comorbidity profiles, socioeconomic indicators, lifestyle‑related exposures, and detailed measures of access to care. Linking these variables with oncologic outcomes may help clarify the mechanisms driving rural–urban disparities and guide the development of cost‑effective, targeted interventions aimed at improving the quality of bladder‑cancer care across geographic settings.’
The CBCIS study provides compelling evidence that rural patients with high‑risk NMIBC in Canada receive lower‑quality care and experience worse PFS. These findings echo international literature and highlight that even in a universal health‑care system, geography remains a structural determinant of cancer outcomes. The challenge now is to translate these insights into targeted interventions that reduce disparities and ensure equitable, high‑quality bladder‑cancer care for all patients—regardless of where they live.
Acknowledgments
None.
Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Translational Andrology and Urology. The article has undergone external peer review.
Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0412/prf
Funding: None.
Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0412/coif). The author has no conflicts of interest to declare.
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