Rural–urban variation in guideline-concordant management of early-stage kidney, prostate, and testicular cancer in the United States (2010–2022)

• Rural residence was associated with lower NCCN-concordant management across early-stage genitourinary cancers. • In clinical T1a kidney cancer, rural counties had lower use of partial nephrectomy despite similar observation rates. • Prostate cancer concordance explicitly incorporated active surveillance eligibility to distinguish appropriate surveillance from undertreatment. • Among men ineligible for active surveillance, rural residence remained associated with lower receipt of definitive local therapy. • Testicular cancer guideline concordance exceeded 90%, with no clear rural–urban gradient. NCCN provides clear recommendations for initial management of early-stage kidney, prostate, and testicular cancer. Whether these pathways are implemented equitably across geographic settings remains uncertain. We evaluated rural–urban differences in NCCN-concordant initial management across three common genitourinary malignancies. Using SEER (2010–2022), we identified adults with clinical T1a kidney cancer, nonmetastatic prostate adenocarcinoma with complete PSA/Gleason/clinical stage, and stage I-II testicular germ-cell tumors. County rurality was defined using USDA Rural-Urban Continuum Codes (urban, rural-adjacent, rural-remote). For kidney cancer, the primary quality endpoint was receipt of partial nephrectomy (PN) vs. radical nephrectomy (RN) or observation/no surgery. For prostate cancer, men were classified as active surveillance (AS)-eligible vs. AS-ineligible using PSA, Gleason score, and clinical T stage. Guideline concordance was defined as AS/observation for AS-eligible disease and definitive local therapy for AS-ineligible disease. Multivariable logistic regression estimated adjusted odds ratios (aORs) by rurality, adjusting for demographic, clinical, and temporal factors. A prespecified analysis restricted to AS-ineligible men evaluated definitive local therapy. Among 516,105 patients (72,681 kidney; 439,435 prostate; 3,989 testicular), rural residence was associated with lower rates of NCCN-aligned initial management. In cT1a kidney cancer, observation/no surgery rates were similar across rurality, but PN was less common in rural counties (57.8% urban vs. 50.5% rural-adjacent vs. 49.9% rural-remote). After adjustment, rural residence remained associated with lower odds of PN (rural-adjacent aOR 0.74, 95% CI 0.70–0.79; rural-remote aOR 0.72, 95% CI 0.67–0.78). In prostate cancer, rural residence was associated with lower guideline-concordant management even after incorporating AS eligibility (rural-adjacent aOR 0.82, 95% CI 0.80–0.84; rural-remote aOR 0.74, 95% CI 0.71–0.76); among AS-ineligible men, adjusted definitive local therapy was also lower in rural counties (81.6% urban vs. 78.5% rural-adjacent vs. 76.8% rural-remote). Testicular cancer guideline concordance exceeded 90%, however rural representation was limited. Despite well-defined NCCN pathways, geographic disparities persist in early-stage GU cancer management. Rural patients remain less likely to receive nephron-sparing surgery for cT1a kidney cancer and guideline-concordant prostate cancer management, including among men who are AS-ineligible and should receive definitive local therapy. Investments in rural surgical and radiation access, coordinated referral networks, and surveillance support infrastructure may reduce persistent gaps.