The COVID-19 pandemic did not make colorectal cancer take a vacation. Unfortunately, it did persuade millions of Americans to postpone the appointments that can prevent the disease or catch it early.
During the first waves of COVID-19, hospitals redirected staff, endoscopy centers reduced capacity, and patients avoided medical facilities. Colorectal cancer screening fell sharply, diagnostic procedures were delayed, and treatment plans became harder to coordinate. These disruptions affected nearly everyone, but they did not affect everyone equally.
Communities already facing limited insurance coverage, transportation problems, language barriers, medical mistrust, or shortages of nearby specialists entered the pandemic with fewer health care options. When the system contracted, those small gaps became potholesand some potholes became canyons.
Why Colorectal Cancer Screening Matters So Much
Colorectal cancer begins in the colon or rectum, often as a precancerous growth called a polyp. Screening can identify cancer before symptoms develop, and certain tests allow doctors to find and remove polyps before they become cancerous.
That makes colorectal cancer screening unusual: it is both an early-detection strategy and, in many cases, a form of cancer prevention.
Stage at diagnosis matters enormously. National Cancer Institute surveillance data show that the five-year relative survival rate for localized colorectal cancer exceeds 90%. The outlook is much poorer after the disease has spread to distant organs. A postponed test is therefore not simply an appointment moved from Tuesday to “sometime after life becomes normal.” It may determine whether a lesion is removed as a polyp or treated later as advanced cancer.
Screening is a process, not a single event
A complete screening pathway can include several steps:
- Receiving a screening recommendation
- Selecting and completing an appropriate test
- Returning a stool-based test correctly
- Receiving and understanding the result
- Completing a colonoscopy after an abnormal stool test
- Beginning treatment promptly if cancer is diagnosed
A delay at any point can weaken the benefit of everything that came before it. Mailing thousands of fecal immunochemical tests, or FIT kits, looks impressive on a spreadsheet. If patients with positive results cannot obtain follow-up colonoscopies, however, the program has delivered envelopes rather than completed cancer screening.
How COVID-19 Disrupted Colorectal Cancer Care
Screening volumes collapsed
In spring 2020, many preventive services were suspended as health systems prepared for COVID-19 cases and conserved protective equipment. Early analyses reported dramatic declines across cancer screening services. Colonoscopy was particularly vulnerable because it requires bowel preparation, specialized staff, procedure rooms, sedation, and close contact.
National survey research later produced a more complicated picture. Between 2018 and 2020, past-year colonoscopy use declined while stool-based screening increased. That substitution prevented the total colorectal screening rate from falling as far as colonoscopy volume alone might suggest. In other words, the system found a spare tirebut not every patient received one.
Fewer diagnoses did not mean less cancer
When reported cancer diagnoses dropped during 2020, cancer had not suddenly become shy. Many cases were simply not being detected.
A federal analysis estimated that 7,147 early-stage colorectal cancers would ordinarily have been diagnosed in 2020, but only 5,983 were recorded. That represented more than 1,100 potentially missed early-stage diagnoses, or a shortfall of roughly 16%.
Some of those cancers may have been detected later. Others may have appeared after symptoms developed, when treatment was more complicated. Delayed diagnosis can require more extensive surgery, chemotherapy, radiation, longer time away from work, and greater out-of-pocket spending.
Treatment disruption added another layer
Patients who had already been diagnosed faced canceled procedures, visitor restrictions, staffing shortages, and concerns about infection during chemotherapy or surgery. Telehealth helped with consultations, but a video call cannot perform a colonoscopy, remove a tumor, or examine persistent rectal bleeding.
Research involving U.S. adults with cancer found that Black and Latino patients reported more delayed cancer care and greater social and economic disruption than White patients during the pandemic. The difference was not merely about personal choices. It reflected unequal exposure to job loss, unstable coverage, caregiving demands, transportation barriers, and COVID-19 itself.
Why the Pandemic Could Widen Colorectal Cancer Disparities
The country did not start from an equal baseline
Long before COVID-19, colorectal cancer outcomes differed by race, ethnicity, income, geography, disability status, and insurance coverage. Black Americans experienced a particularly high colorectal cancer burden and mortality rate. American Indian and Alaska Native communities also faced high incidence in several regions, while many Hispanic and Asian American populations encountered lower screening rates connected to access, language, and insurance barriers.
Income is another powerful dividing line. CDC data for 2021 showed that recommended colorectal cancer screening among adults ages 50 to 75 increased substantially with family income. People living below the federal poverty level were far less likely to be current with screening than those with higher incomes.
Essential work often came with fewer health care options
Many lower-wage employees could not work remotely, yet they were less likely to have flexible schedules or paid medical leave. Preparing for a colonoscopy can require time off before and after the procedure, as well as an adult to provide transportation home. That arrangement is inconvenient for almost anyone. For a worker whose paycheck shrinks with every missed shift, it may be financially impossible.
The pandemic intensified these pressures. A patient might have needed to choose among screening, rent, child care, and keeping a job. Preventive medicine rarely wins a contest against tonight’s groceries.
Insurance and transportation became less stable
Employer-sponsored insurance can disappear when employment disappears. Even when coverage continues, deductibles, unclear billing rules, and concern about the cost of follow-up care may discourage screening.
Transportation networks also changed. Public transit services were reduced in some communities, volunteer transportation programs paused, and patients worried about virus exposure during long trips. Rural residents already traveling considerable distances to reach an endoscopy center faced an even higher hurdle.
The digital divide followed patients into telehealth
Telemedicine preserved access for many people, but its benefits depended on broadband service, a suitable device, digital literacy, privacy, and language access. Patients without those resources could miss referrals or instructions. A glitchy connection is mildly amusing during a family video call; it is much less charming when someone is trying to understand an abnormal cancer screening result.
The new starting age created an implementation challenge
In 2021, the U.S. Preventive Services Task Force lowered the recommended starting age for average-risk colorectal cancer screening from 50 to 45. The change was important because colorectal cancer incidence has been rising among younger adults.
However, the recommendation arrived while many practices were still managing backlogs. Adults ages 45 to 49 became newly eligible just as health systems were trying to locate older patients who had missed screening. People without a regular primary care clinician were especially likely to remain unaware that the guidance had changed.
What Later Evidence Says About the Pandemic’s Impact
The long-term picture is serious but more nuanced than the bleakest early forecasts. National data suggest that portions of the screening system recovered, and stool-based testing helped compensate for reduced colonoscopy access. In 2021, approximately one in four screening-eligible adults was not up to date, although overall use of some tests had returned near prepandemic levels.
By 2023, national colorectal cancer screening indicators had improved after stalling during the pandemic. Researchers have not found a uniform, nationwide explosion of late-stage disease attributable solely to the shutdown period. That is reassuring, but national averages can conceal unequal recovery.
One community may clear its colonoscopy backlog quickly while another continues to struggle with specialist shortages. An insured patient with a primary care clinician may receive three reminders and a mailed FIT kit. An uninsured neighbor may receive neither. When both are averaged together, the result can look comfortably ordinary while the underlying gap grows.
Modeling shows why catch-up efforts matter
NCI-supported modeling studies suggest that temporary screening disruptions can produce preventable colorectal cancer cases and deaths if missed tests are never completed. The projected harm becomes smaller when health systems actively catch up overdue patients.
Recovery also needs to be equitable. If higher-income populations return to screening first while historically underserved populations remain behind, overall screening rates may improve even as disparities worsen. A rising average does not guarantee a rising floor.
Strategies That Can Reduce the Screening Gap
Offer more than one appropriate screening option
Adults at average risk may have several screening choices, including colonoscopy and stool-based tests. FIT can usually be completed at home and returned by mail, making it valuable when procedure capacity, transportation, or paid leave is limited.
Patients should understand that an abnormal stool test requires a timely colonoscopy. Health systems should arrange that follow-up as part of the screening program, rather than leaving patients to navigate a specialist maze while holding an alarming laboratory result.
Use patient navigation
Patient navigators can explain preparation instructions, identify transportation assistance, coordinate referrals, address language needs, and help resolve insurance questions. Navigation is especially effective because it treats barriers as practical problemsnot as evidence that patients “do not care” about prevention.
Build community partnerships
Tribal health programs, community health centers, churches, pharmacies, employers, and local advocacy organizations can reach residents who may not receive reminders from a large medical system. One CDC-supported tribal initiative used education and reminders during the pandemic and increased the percentage of participating patients who were current with colorectal cancer screening.
Track completion by population group
Health systems should measure who receives screening, who returns a kit, who has an abnormal result, and who completes diagnostic colonoscopy. Results should be examined by race, ethnicity, preferred language, insurance, ZIP code, disability, and other relevant factors.
Without that detail, organizations can celebrate the number of tests mailed while overlooking the neighborhood where most kits never arrived.
Make screening easier to complete
Useful approaches include evening appointments, mobile services, mailed FIT programs, reminder calls, text messages, transportation assistance, multilingual instructions, and direct scheduling after an abnormal result. These are not glamorous innovations. They are the health care equivalent of putting a handle on a heavy boxand they work because they make the next step manageable.
What Individuals Should Know Now
Adults at average risk should generally begin colorectal cancer screening at age 45 and continue through age 75. Screening from ages 76 to 85 is usually based on personal health, prior screening history, preferences, and a clinician’s recommendation.
Some people need earlier or more frequent testing, including those with a personal or family history of colorectal cancer or certain polyps, inflammatory bowel disease, or a hereditary cancer syndrome.
Screening recommendations apply to people without symptoms. Anyone experiencing rectal bleeding, blood in the stool, persistent changes in bowel habits, unexplained weight loss, ongoing abdominal discomfort, weakness, or iron-deficiency anemia should contact a health professional. Symptoms deserve evaluation regardless of age or when the last screening test occurred.
Pandemic-Era Experiences: What Patients and Clinics Learned
The following composite experiences reflect recurring barriers described in U.S. studies and public-health programs. They are illustrative scenarios, not accounts of specific identifiable patients.
The screening that kept moving to next month
Consider a 57-year-old hourly employee whose routine colonoscopy was canceled in spring 2020. The endoscopy center eventually reopened, but her work schedule had changed, her spouse could no longer drive her, and taking unpaid leave meant losing money needed for utilities.
Each obstacle looked temporary. Together, they produced a delay lasting more than a year. A mailed FIT kit finally allowed her to restart screening at home. When the result was abnormal, a patient navigator coordinated the colonoscopy, transportation, and instructions.
The lesson is not that a stool test is always better than colonoscopy. It is that an appropriate test a patient can complete is more useful than an idealized plan that remains permanently penciled into the calendar.
The telehealth appointment that did not solve the problem
Imagine a Spanish-speaking patient with intermittent rectal bleeding who arranged a telehealth visit using a relative’s phone. Audio problems interrupted the conversation, interpretation was delayed, and the patient believed the bleeding was probably caused by hemorrhoids. Because COVID-19 cases were high locally, an in-person evaluation felt dangerous.
Months later, worsening fatigue led to an emergency visit and a diagnosis of anemia. The care team then expedited diagnostic testing.
This experience illustrates why telehealth must include reliable interpretation, clear safety-net instructions, and an easy route to in-person assessment. Technology can open the front door to care, but it should not become a digital waiting room with no exit.
The clinic that discovered mailing kits was only step one
A community health center may have responded to reduced colonoscopy capacity by mailing hundreds of FIT kits. Initial numbers looked excellentuntil staff examined how many kits were returned and how many positive results led to colonoscopy.
Some patients had moved. Others did not understand the instructions, lacked reliable mail service, or feared a bill if the result required additional testing. The clinic revised its program by confirming addresses, adding multilingual instructions, calling patients before shipment, and reserving diagnostic colonoscopy appointments.
Completion improved because the clinic stopped treating every unreturned kit as a personal failure. Instead, it examined the system surrounding the patient.
The shared lesson
These experiences reveal a central truth about colorectal cancer disparities: access is more than the theoretical availability of a test. Real access means a patient can learn about screening, obtain the test, understand it, afford the next step, travel to necessary care, and receive treatment without getting lost between departments.
The pandemic exposed how fragile that chain could be. It also demonstrated that flexible screening, community outreach, navigation, and deliberate follow-up can repair it. The goal is not merely to restore the health system that existed in February 2020. It is to build one that reaches the people the old system routinely missed.
Conclusion
COVID-19 disrupted colorectal cancer screening and care across the United States, but its greatest risks fell on communities already facing unequal access. Missed tests, delayed diagnoses, unstable insurance, limited transportation, and uneven recovery may deepen existing colorectal cancer disparities for years.
The outcome is not predetermined. Mailed stool tests, timely follow-up colonoscopy, patient navigation, community partnerships, multilingual communication, and detailed equity tracking can recover missed screenings and prevent future deaths. Colorectal cancer is famously unimpressed by excuses, backlogs, and scheduling software. A health system designed to complete every step of screening gives more people the chance to find it earlyor prevent it altogether.
Evidence Base
This article synthesizes information from the Centers for Disease Control and Prevention, Annual Report to the Nation, Preventing Chronic Disease, National Cancer Institute, Cancer Intervention and Surveillance Modeling Network, SEER, American Cancer Society, ACS Cancer Prevention and Early Detection Report, JAMA Network Open screening research, JAMA Network Open cancer-care research, JAMA Health Forum, eLife modeling research archived by NIH, President’s Cancer Panel, and KFF.
