A manuscript published in the December 2025 journal Cancer Causes & Control, “Bridging the Rural Cancer Gap: Why Clinical Trials Must Include Rural Patients,” highlights the underrepresentation of rural populations in oncology trials, key barriers to participation, and strategies to overcome them, including national and international models for inclusive trial design.
Although rural areas report fewer new cancer cases than urban regions, rural patients experience significantly higher mortality, particularly for preventable cancers like lung, colorectal, and cervical cancer. Research access mirrors this divide: Rural Americans remain consistently underrepresented in oncology clinical trials, even as evidence demonstrates that participation increases when inclusion is intentionally built into trial design.
The consequences are twofold: Rural communities miss out on novel treatments, and oncology research loses the ability to produce evidence that reflects the diversity of US patients.
Why Rural Patients Are Left Out of Research
The manuscript outlines several interconnected reasons why rural participation in cancer trials remains low.
Geographic and Logistical Barriers
Distance is one of the most prohibitive obstacles. Most trials occur at large academic centers concentrated in metropolitan areas, leaving rural patients with long travel times, multiple required visits, and limited support for transportation or lodging. For those with rigid work schedules, childcare needs, or caregiving responsibilities, participation becomes nearly impossible.
Financial Toxicity
Even when patients are eligible, the out‑of‑pocket costs of participation—lost wages, transportation, lodging—create burdens that are less likely to severely impact patients in urban areas. Rural participants also have fewer subsidized accommodation options near cancer centers, widening the financial divide and making trial participation a significant hardship.
Limited Local Research Infrastructure
Many rural hospitals lack the infrastructure needed to support trials, such as research coordinators, institutional review boards, data systems, or oncology specialists trained in clinical research. As a result, trials that could potentially be delivered locally remain inaccessible. Smaller rural patient populations also pose statistical and economic challenges, making trial activation less appealing to sponsors and reinforcing the cycle of exclusion.
Cultural and Communication Barriers
Mistrust of medical research in rural communities has historical roots and is reinforced by a sense that major scientific institutions are distant from local needs. The manuscript also notes that rural residents are more likely to be perceived by investigators as lacking knowledge about clinical trials—an assumption that undermines engagement and perpetuates inequity.
Strategies That Show Promise
Despite these barriers, the manuscript identifies several meaningful and scalable strategies that can expand rural access to clinical trials.
Immediate, High-Feasibility Approaches
Travel and lodging reimbursement can directly increase enrollment by reducing financial toxicity—one of the most modifiable barriers. Decentralized and hybrid trial models, such as telehealth visits, remote consent, and use of local labs or imaging centers, can reduce the need for long-distance travel. A recent analysis found no evidence that pandemic-era decentralization undermined trial quality, easing concerns about data integrity.
Medium-Term Strategies
Expanding trial sites to community hospitals and critical access facilities can bring research closer to rural patients. The NCI Community Oncology Research Program—which includes rural practices across two-thirds of its network—demonstrates how infrastructure investments can improve rural representation and help national network trials more accurately reflect rural communities.
Similarly, hub-and-spoke models, in which academic centers partner with rural hospitals and supply them with dedicated staff, can make trial participation operationally feasible at smaller sites.
Long-Term, Structural Solutions
Policy interventions—including reimbursement mandates for travel support, dedicated federal funding for rural trial infrastructure, and regulatory or financial incentives for sponsors that activate rural sites—are critical for durable change. These measures, paired with culturally responsive communication and partnerships with trusted local providers, can rebuild trust and create lasting pathways into research for rural communities.
Why This Matters
Excluding rural populations from oncology clinical trials is not a minor oversight; it is a barrier to equity, outcomes, and scientific progress. As the manuscript emphasizes, the purpose of cancer research is to improve survival and quality of life. That promise cannot be fully realized if entire communities are excluded from the data collection shaping modern cancer care.
Bringing rural patients into the research landscape requires partnership—not only from researchers and sponsors, but also clinicians, health systems, policymakers, and community leaders. When rural patients can participate in trials without leaving their support systems behind, scientific discovery benefits.
The path forward is clear: Intentional design, meaningful investment, and community centered approaches can ensure that innovation in cancer care extends to every corner of the US.
