Road to post-pandemic recovery: Regional equity in colorectal cancer screening in the U.S.

246 Background: Colorectal cancer (CRC) screening is a foundational cancer prevention strategy. However, the COVID-19 pandemic led to disruptions in preventive care services across the U.S. While studies have begun to assess its overall impact, limited understanding exists of whether screening rates have rebounded equitably across U.S. regions and sociodemographic groups. To address this, we analyzed national and regional CRC screening trends before (2018), during (2020), and after the height of the pandemic (2022). Methods: We conducted a cross-sectional analysis of Behavioral Risk Factor Surveillance System data from 2018, 2020, and 2022. Adults aged 50–75 years who met U.S. Preventive Services Task Force CRC screening criteria (n = 628,263) were included. Records with missing data or covariates were excluded. Survey-weighted prevalence was calculated nationally and by census region. Multivariable logistic regression was used to estimate adjusted odds (aOR) of screening across years, regions, and covariates (age, sex, race/ethnicity, education, income, employment, insurance, and recent primary care visit), with 95% confidence intervals (CI) and p-values. Results: National CRC screening prevalence declined from 64.1% in 2018 to 61.3% in 2022. The West experienced the largest decrease (−4.3%) with no recovery, while the Midwest showed a modest rebound (+0.8%). In the Northeast, screening rates remained stable through 2020 but declined by 3.1% in 2022. Meanwhile, in the South, screening rates rose by 0.5% in 2020, but fell by 1.8% in 2022. Hispanic, uninsured, and unemployed adults consistently had the lowest screening prevalence. In adjusted analyses, screening odds significantly declined from 2018 to 2022 only in the West (aOR = 0.87, 95% CI 0.81, 0.94). Nationwide, Asian adults had the lowest odds of screening (aOR = 0.58, 95% CI 0.52, 0.65), followed by American Indian/Alaska Native and Hispanic adults. Disparities were most pronounced in the Northeast (Asian vs. White aOR = 0.54, 95% CI 0.46, 0.64) and least in the Midwest (Asian vs. White aOR = 0.64, 95% CI 0.51, 0.8). Higher screening odds were associated with older age, female sex, higher income and education, and being retired or disabled. The strongest predictor of CRC screening was a recent primary care visit (aOR = 3.04, 95% CI 2.93, 3.14). All p-values were < 0.001. Conclusions: Persistent regional and sociodemographic disparities in CRC screening were most pronounced in the Northeast and among Asians, American Indians/Alaska Natives, Hispanics, uninsured, and unemployed adults. This underscores critical equity gaps in post-pandemic recovery. These findings provide a clear, data-driven basis for regionally tailored, equity-focused interventions, such as targeted outreach, insurance expansion, and strengthened primary care access, to restore screening rates and reduce preventable cancer care disparities.