The research team, led by investigators at Case Western Reserve University School of Medicine, identified 951,965 men aged 40 and older diagnosed with primary prostate cancer across SEER’s 17 registries, which collectively cover roughly 26.5 percent of the U.S. population. Using county-level Federal Information Processing Standards codes, the scientists sorted every case into four geographic categories: urban Appalachian, rural Appalachian, urban non-Appalachian, and rural non-Appalachian. Rurality was classified with the U.S. Department of Agriculture’s 2013 Rural-Urban Continuum Codes, grouping metropolitan counties (codes 1 through 3) as urban and non-metropolitan counties (codes 4 through 9) as rural.

Aggressiveness was defined with clinical precision. A case was labeled more aggressive if it met at least one of three criteria assessed at diagnosis: a Gleason score of 7 with a 4+3 pattern or scores of 8 through 10, tumor stage T3 or T4, or distant metastasis. Less aggressive disease was confined to Gleason scores of 6 or 7 with a 3+4 pattern, tumor stage T1 or T2, and no distant spread. This composite approach, the authors note, aims to capture clinically meaningful disease severity rather than long-term outcomes, and only 4.1 percent of cases had unknown aggressiveness status, with missingness similar across all geographic groups.

The headline finding concerns time. While overall prostate cancer incidence declined in most regions, the age-adjusted incidence of more aggressive disease rose significantly in both Appalachian categories. Urban Appalachia saw aggressive prostate cancer incidence climb at an annual percent change of 2.73 percent (95 percent confidence interval 1.20 to 4.65), and rural Appalachia rose at 1.91 percent (95 percent CI 0.61 to 3.39). Rural non-Appalachia also increased, though more slowly at 0.97 percent. Meanwhile, rural Appalachia was the only region with a consistent decline in overall incidence, falling at an annual percent change of minus 1.7 percent (95 percent CI minus 2.98 to minus 0.42). After 2016, urban Appalachia showed larger rises than any other region, with notable spikes in 2016, 2017, and 2021.

Metastatic disease told a parallel story. Urban Appalachia recorded the lowest overall metastatic incidence at 11.16 per 100,000 men, while rural non-Appalachia had the highest at 13.86 per 100,000. Rates generally declined through the late 2000s before rebounding, and all four regions increased substantially after 2020, with the overall metastatic rate jumping from 15.30 per 100,000 men in 2020 to 18.32 in 2021 and 19.26 in 2022. The authors attribute this post-pandemic surge to delayed diagnoses stemming from disruptions in PSA screening and routine care during the COVID-19 pandemic, a pattern also documented by the Centers for Disease Control and Prevention.

Multivariable logistic regression exposed how geography and race interact in ways that defy simple assumptions. Among White men, compared with urban non-Appalachia, the odds of more aggressive prostate cancer were higher in rural non-Appalachia (odds ratio 1.077) and rural Appalachia (odds ratio 1.035) but lower in urban Appalachia (odds ratio 0.916). Black men overall faced higher odds of aggressive disease than White men, with the disparity most pronounced in urban areas: odds ratios of 1.085 in urban non-Appalachia and 1.160 in urban Appalachia. Yet in rural Appalachia, the pattern reversed, with Black men showing significantly lower odds of aggressive disease than White men in the same region (odds ratio 0.831), a finding the authors suggest may reflect lower screening uptake and smaller Black populations in those counties.

The paradox of Appalachia, where overall incidence falls while aggressive disease rises, may be rooted in screening behavior. Prior studies cited in the paper found that Appalachian men were 1 to 2 percentage points less likely than age-matched non-Appalachian men to have ever received a serum PSA test or digital rectal examination. Lower screening rates, the researchers propose, could suppress the detection of less aggressive, screen-detected tumors while allowing more dangerous cancers to progress undetected until they present with advanced disease. The authors also point to the evolution of U.S. Preventive Services Task Force guidelines, which recommended against routine PSA screening for men 75 and older in 2008 and against PSA-based screening for all men in 2012, shifts that may have disproportionately affected older and high-risk populations in underserved regions.

Rural areas face compounding structural barriers. The study found that men in rural regions were diagnosed at older ages, more likely to present with aggressive disease, and less likely to receive definitive treatment than their urban counterparts. The authors cite longer travel distances, transportation limitations, fewer healthcare providers and specialists, shortages of urologists, and socioeconomic disadvantages as plausible mechanisms driving more advanced disease at initial diagnosis. Appalachian Regional Commission data indicate substantially lower availability of primary and specialty physicians in rural Appalachian counties than in large metropolitan ones. Notably, the gap between Appalachian and non-Appalachian incidence narrowed between 2011 and 2015, following the Affordable Care Act’s expansion of Medicaid eligibility and increased funding for local health departments in Appalachia, though the authors caution that Medicaid expansion was not uniform across SEER states.

The study carries important caveats. SEER’s coverage of roughly 26.5 percent of the population does not capture the full geographic and demographic diversity of Appalachia, limiting generalizability to the most rural or socioeconomically disadvantaged areas. The researchers used the Appalachian Regional Commission’s 2008 county definition despite later updates, and rurality was based on the USDA’s 2013 codes, which may not reflect temporal shifts in urbanization over the nearly two-decade study window. The authors also note that grouping all non-metropolitan counties into a single rural category may mask important variation in healthcare access, and that relatively small effect sizes, while statistically significant given the enormous sample, should be interpreted with attention to both magnitude and precision.

Still, the implications are clear. Prostate cancer remains the second most commonly diagnosed cancer among American men, with the American Cancer Society estimating approximately 299,010 new cases and 35,250 deaths in 2024. The finding that aggressive disease is climbing in Appalachian communities while overall rates fall suggests that targeted screening outreach, improved access to urological specialists, and race-conscious care strategies are urgently needed in these regions. The authors conclude that prostate cancer burden and severity varied meaningfully by Appalachian status and rurality, and that monitoring these evolving temporal trends will be essential to closing the gap before more dangerous cancers slip through the diagnostic net.

Subject of Research: Geographic disparities and temporal trends in aggressive prostate cancer: a SEER population-based analysis (2004–2022)

Article Title: Geographic disparities and temporal trends in aggressive prostate cancer: a SEER population-based analysis (2004–2022)

Article References: Xu, Y., Singh, A., Li, E., Zaorsky, N. G., Geyer, N., Yang, Y., Yang, Y., McDonald, A. C., Zhang, L., & Wang, M. (2026). Geographic disparities and temporal trends in aggressive prostate cancer: a SEER population-based analysis (2004–2022). Cancer Causes & Control, 37(11), Article 181. https://doi.org/10.1007/s10552-026-02267-5

Image Credits: AI Generated

DOI: 10.1007/s10552-026-02267-5

Keywords: prostate cancer, health disparities, Appalachia, rural health, cancer epidemiology, SEER database, public health, Geographic, disparities, temporal, trends, aggressive

The study, published as a short report in Archives of Dermatological Research, was conducted by a team from Northeast Ohio Medical University led by medical students Jacob Fay and Natasha Salmen, with dermatologist Eliot Mostow serving as principal investigator. Their approach was elegantly simple: they queried the NPPES registry for providers listing a dermatology taxonomy code and matched each provider’s primary address zip code to the Appalachian Regional Commission’s interactive mapping tool, which delineates the region’s county boundaries. This cross-sectional methodology allowed them to generate a county-by-county census of dermatologists without relying on surveys or voluntary self-reporting, two approaches that often undercount or skew physician workforce data.

The numbers they assembled are striking in their unevenness. In total, 870 dermatologists were identified across the entire 205,000-square-mile region, a stretch that runs from southern New York to northeastern Mississippi. Pennsylvania reported the highest count at 238 dermatologists, while Mississippi reported the lowest at just 10 spread across 24 Appalachian counties. The median county density was 0.00 dermatologists per 100,000 residents, a figure that technically means more than half of all Appalachian counties contain no dermatologist whatsoever. The interquartile range of 0.00 to 2.01 per 100,000 underscores how compressed the distribution is: even among counties that do have specialists, most have only a handful.

Concentration is the defining feature of the data. The ten counties with the most dermatologists collectively accounted for 409 of the 870 providers, or 47.0 percent of the entire regional workforce. In other words, fewer than 2.4 percent of Appalachian counties host nearly half of the region’s skin specialists. This pattern mirrors a well-documented national trend. Previous research published in JAMA Dermatology has shown that dermatologist density in the United States is strongly correlated with urbanization, with rural counties consistently falling below urban ones in specialists per capita. The Appalachian analysis extends that finding into a region where rurality, mountainous terrain, and economic hardship compound one another.

To capture that variation, the researchers turned to the Appalachian Regional Commission’s own subregional framework, which divides the region into five zones: North, North Central, South, South Central, and Central Appalachia. Aggregated dermatologist density ranged from a high of 4.27 per 100,000 residents in South Central Appalachia to a low of 1.41 per 100,000 in Central Appalachia, the subregion that includes eastern Kentucky and southern West Virginia. Even the best-performing subregion falls short of densities reported in major metropolitan areas nationally, and the gap between the highest and lowest subregions is roughly threefold, suggesting that scarcity is not evenly shared even within this already disadvantaged region.

Perhaps the most sobering finding emerged when the researchers cross-referenced dermatologist presence with the Appalachian Regional Commission’s county economic classification system, which grades counties from distressed to attainment based on unemployment, income, and poverty metrics. Distressed counties, the most economically struggling tier, lacked a dermatologist in 70 of 77 cases, a rate of 90.9 percent. By contrast, competitive counties lacked one in only 28.6 percent of cases, and attainment counties, the strongest economic tier, had a dermatologist in every single one of the three counties so classified. The gradient is nearly monotonic: as economic status improves, the probability of having local skin care access rises sharply, a correlation that hints at the self-reinforcing nature of regional health disadvantage.

The clinical stakes of this shortage are considerable. Dermatology is a visually diagnostic specialty, and conditions such as melanoma depend heavily on early detection for favorable outcomes. Melanoma mortality in rural America has been rising even as urban rates stabilize, and delayed diagnosis of skin cancers, infections, and inflammatory diseases is a plausible downstream consequence of specialist scarcity. Patients without a local dermatologist must weigh long drives over mountain roads, lost wages, and childcare against the perceived urgency of a suspicious mole or a worsening rash, and many simply defer care until disease progresses. The study’s authors note that limited dermatologic care in these areas may contribute to the poor health outcomes that have long characterized the region.

The researchers are candid about the limitations of their method. The NPPES registry records a provider’s primary practice address, which may not reflect where the clinician actually sees patients; some dermatologists listed in urban-adjacent counties may hold outreach clinics elsewhere, while others may have retired or changed specialties without updating their registry information. The cross-sectional design also captures only a single moment in time, so it cannot track whether the workforce is growing or shrinking. Taxonomy-based identification may likewise miss physicians who perform dermatologic procedures under different designations. These caveats mean the true picture could be somewhat better or worse than the snapshot suggests, though the authors argue the overall pattern of severe maldistribution is robust.

What emerges from the data is a roadmap for intervention. The authors point to expanded service models, most notably teledermatology, in which store-and-forward imaging or live video consultations connect primary care providers in underserved counties with board-certified dermatologists elsewhere. Teledermatology has shown strong diagnostic concordance with in-person evaluation for many conditions and could dramatically shrink the effective distance between Appalachian patients and specialist expertise. They also advocate targeted workforce planning aimed at the persistently underserved counties identified in the analysis, alongside outreach clinics and mobile services that bring periodic specialist care into communities that would otherwise never see it. Because the study pinpoints exactly which counties lack providers, it offers policymakers a concrete prioritization list rather than a vague call for attention.

Beyond its immediate findings, the study demonstrates the power of publicly available administrative data to illuminate health care deserts with remarkable granularity. The NPPES registry is free, comprehensive, and updated continuously, making it a reusable surveillance tool for any specialty or region. As the United States grapples with a projected physician shortage and widening rural-urban health gaps, this kind of registry-driven mapping offers a low-cost way to direct resources where they are needed most. For the residents of the 277 Appalachian counties without a single dermatologist, the hope is that precise data will translate into political will, and that the next census of the region’s skin specialists will find far fewer empty counties on the map.

Subject of Research: Geographic distribution of dermatologists and dermatologic care access across the Appalachian region

Article Title: A cross-sectional analysis of the distribution of dermatologists in the appalachian region using the national plan and provider enumeration system national provider identifier registry

Article References: Fay, J., Salmen, N., Lufi, V., Nallapaneni, S., & Mostow, E. (2026). A cross-sectional analysis of the distribution of dermatologists in the appalachian region using the national plan and provider enumeration system national provider identifier registry. Archives of Dermatological Research, 318(1), Article 464. https://doi.org/10.1007/s00403-026-04903-1

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04903-1

Keywords: dermatology, Appalachia, physician distribution, health disparities, NPPES registry, rural health, teledermatology, workforce shortage, skin cancer, health care access, Appalachian Regional Commission, cross-sectional study