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Background  Gastric cancer is one of the most prevalent cancers in the world and the third most common cause of death from cancer. The diagnosis and treatment are often complex and require a multifaceted approach. Hence, appropriate and timely management is essential for better patient outcomes. Our aim was to determine if rural inhabitation affects the mortality of patients with gastric adenocarcinoma. If such an association exists, we propose to ascertain whether this is related to delayed diagnosis, differing tumor characteristics, or treatment inequalities.  Methods  The Cox model was applied to gastric adenocarcinoma cases diagnosed during 2004-2011 in American residents aged 20+ years in the Surveillance, Epidemiology, and End Results (SEER) program to determine the impact of rurality on mortality. Binary logistic regression was used to compare the odds of not receiving surgical treatment for localized tumors between rural and urban areas. It was also used to measure the association of rurality with stage at diagnosis (non-metastatic vs. metastatic).  Results  There was a significant association of rurality on 5-year mortality [HR 1.14 (1.09-1.20), p < 0.01]. No significant association was observed between rural-urban residency and stage at diagnosis, with an odds ratio (OR) of 0.95 (0.87-1.03), p = 0.21. The median time from diagnosis to any first-course treatment was one month for both rural and urban counties. Rural residents were far more likely not to receive surgical treatment for localized tumors than their urban counterparts [OR 1.70 (1.41-2.05), p < 0.01]. A greater percentage of rural inhabitants had cardia tumors as compared to urban ones, 39.8% vs. 33.8% respectively. Non-cardia tumors were far less likely not to receive surgical treatment (i.e., more likely to receive surgical treatment) than cardia tumors [OR 0.35 (0.30-0.41), p < 0.01].  Conclusions  Rurality is associated with worse gastric adenocarcinoma mortality. This may be due to a lesser probability of receiving surgical treatment for early-stage disease and differences in the primary site of the tumor between rural and urban counties, but not due to differences in stage at presentation. Future research should focus on improving health care access in rural communities.

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The Association of Rural-Urban Inhabitation With Gastric Adenocarcinoma Mortality and Treatment: A Surveillance, Epidemiology, and End Results (SEER)-Based Study