State-level trends in colorectal cancer incidence and stage before and during the COVID-19 pandemic.

e15709 Background: Colorectal cancer (CRC) incidence differs across U.S. states, in part reflecting socioeconomic and rural differences as to where patients are diagnosed. During the COVID-19 pandemic, disruptions to routine care raised concern for delayed CRC detection and shifts toward more advanced disease at diagnosis. Methods: We analyzed CRC incidence using NAACCR Cancer in North America (CiNA) public-use data (1995–2022) for the 50 U.S. states and the District of Columbia. Age-adjusted incidence rates (per 100,000; standardized to the 2000 U.S. population) were examined for a pre-pandemic baseline (2010–2019), the pandemic year (2020), and early recovery (2021–2022). Socioeconomic context was defined using census-tract poverty and rurality (metro vs non-metro). We assessed baseline state-level incidence patterns, pandemic-related changes, and variation by socioeconomic and rural context. Stage at diagnosis was examined by race and ethnicity, stage and grade by socioeconomic context, and 2020 incidence changes were compared between screening-eligible adults (45–75 years) and younger adults (15–44 years). Results: Baseline CRC incidence varied substantially across states and was higher in states with a greater proportion of cases from high-poverty, non-metro areas (increase of 0.38 cases per 100,000 per 1% increase in this case mix; p < 0.001). In 2020, CRC incidence declined in all states (median −13.8%; interquartile range [IQR] −16.5% to −11.1%), with partial recovery in 2021–2022 (median −6.6%; IQR −9.4% to −3.8%). The magnitude of the 2020 decline did not differ meaningfully by socioeconomic or rural composition; however, states with more disadvantaged rural case mixes often experienced smaller-than-expected declines compared with national patterns. Across all racial and ethnic groups, the proportion of CRC diagnosed at regional or distant stage increased by 2.0 to 7.4 percentage points in 2020 and remained elevated in 2021–2022. Differences in stage and grade by socioeconomic status and rurality were modest. In age-stratified analyses, CRC incidence declined among screening-eligible adults aged 45–75 (median −13.9%; IQR −15.5% to −10.1%), whereas incidence among adults aged 15–44 did not show a comparable decline (median +7.9%; IQR +1.1% to +16.2%), yielding a median between-group difference of −19.0 percentage points. Conclusions: The COVID-19 pandemic was associated with a nationwide reduction in CRC diagnoses, incomplete recovery through 2022, and a shift toward later-stage disease. Socioeconomic and rural contexts influenced baseline CRC burden but explained only part of pandemic-related changes. Younger adults did not experience a comparable decline, consistent with disruption of screening-dependent detection pathways. These findings highlight the need to re-engage CRC screening and ensure timely diagnostic evaluation across diverse populations.