Glioblastoma (GBM) is the most common and lethal primary malignant brain tumor in adults, accounting for approximately 51.5% of all malignant central nervous system (CNS) tumors in the United States [1]. The age-adjusted incidence is about 4.50 per 100,000 population, with peak occurrence between 65 and 75 years [1]. Despite advances in molecular classification (e.g., Isocitrate Dehydrogenase-wildtype (IDH-WT), TERT promoter mutation, EGFR amplification), prognosis remains dismal [2]. The landmark protocol that includes maximal safe resection followed by radiotherapy (60 Gy in 30 fractions) with concurrent TMZ (75 mg/m² daily) and six cycles of adjuvant TMZ (150–200 mg/m²) has established a median overall survival (mOS) of about 14.6 months in clinical trial settings [3]. However, real-world cohorts consistently report median OS of 10–13 months, with 5-year survival below 10% [4, 5].

Treatment completion is a critical determinant of outcome. Gross total resection (GTR), when feasible, improves OS by 3–6 months compared to biopsy alone, while omission of TMZ or radiation independently worsens prognosis [6]. Yet, sociodemographic and geographic barriers significantly impair adherence. Rural patients, who comprise 19.3% of the U.S. population but 60–70% in states like West Virginia (WV), face prolonged travel distances (often > 100 miles), delayed specialist referral, lower clinical trial enrollment, and higher rates of uninsured or underinsured status [7, 8]. These factors contribute to treatment delays, incomplete multimodal therapy, and inferior survival across multiple cancer types [9].

In neuro-oncology, rural-urban disparities are less well-characterized. Surveillance, Epidemiology, and End Results (SEER) registry analyses suggest rural residence increases mortality risk in “brain and other CNS cancers” (HR 1.08–1.15), but aggregate data obscure GBM-specific effects [10]. A 2021 meta-analysis of 12 studies found rural patients with high-grade gliomas were 20% less likely to receive standard chemoradiation, though survival differences were inconsistent after adjustment for treatment receipt [11]. Notably, a single-institution study from an NCI-designated cancer center reported equivalent OS between rural and urban GBM patients when treated within a centralized multidisciplinary program, suggesting that access to high-volume neuro-oncology care may mitigate geographic inequity [12].

WV exemplifies rural healthcare challenges: 64% of its population resides in rural counties, the highest proportion in the eastern U.S., with persistent deficits in subspecialty access, broadband connectivity, and socioeconomic resources [13]. WVU Ruby Memorial Hospital, and the state’s neuro-oncology referral center, serves a catchment area of over 1.8 million across 55 counties. Mostly, all complex GBM cases, regardless of rurality, are referred to WVU Ruby Memorial Hospital and WVU Cancer Institute, enabling standardized diagnostic workup including molecular work up, treatment planning, and longitudinal follow-up.

We conducted a retrospective cohort study of 380 adults with pathologically confirmed IDH-WT GBM treated at WVU Ruby Memorial Hospital from 2015 to 2025 to evaluate survival differences by treatment (surgery, radiation, TMZ), and demographic factors (age, sex). Kaplan–Meier (KM) estimates and Cox proportional-hazards models were used to assess independent predictors of OS. We hypothesize that the survival benefits observed with centralized neuro-oncology care, are driven predominantly by uniform treatment use, could eliminate previously reported rural disparities in GBM outcomes, with important implications for regional referral networks and health policy in underserved regions.