Using primary data collected from residents across the 82-county Siteman catchment area in Missouri and Illinois, we learned that 21% to 57% of cancer screening or treatment appointments were canceled from March 2020 through the end of 2020. Across all races, residents with higher educational attainment had 1.25 higher odds of care disruption for general or cancer care compared to residents with lower educational attainment; this association remained significant among Black and White residents. Additionally, White residents of older age, assigned female at birth, or having scheduled a telehealth appointment, also had higher odds of care disruption. Finally, knowing their doctor’s office or clinic is taking the appropriate COVID-related safety precautions was the greatest reported need for returning to care (33.8%).

Delays in cancer screening can lead to stage shifts where patients are diagnosed at later stages and thus have a higher risk for cancer morbidity and mortality. Understanding which screenings were impacted and for whom and identifying patient concerns can inform community outreach and engagement efforts. This allows programs to target groups most likely to have delayed screening and draft messaging that can alleviate patient concerns and in turn facilitate a return to care.

Mammograms and Pap tests are an area of increased interest for our catchment area given the high number of women scheduled for screening. Approximately 38% of the 170 women who were scheduled for mammograms had delayed or canceled appointments. Similarly, 45% of the 188 women scheduled for Pap tests had delayed or canceled appointments. Delays in colorectal cancer screening impacted a smaller number of people, but colorectal cancer screening is an important area given the high proportion of cancellations, overall low number of scheduled appointments in general, and high colorectal cancer disparities in the region. Of the 51 people scheduled for a colonoscopy, 57% delayed or canceled appointments, and of the 38 scheduled for a blood stool test, 29% delayed or canceled appointments as well. To help healthcare systems reduce the cancer screening deficit, community outreach and engagement strategies need to address these needs. For example, employing mobile strategies such as the use of mobile mammography and home-based cervical and colorectal cancer screening tests could serve those most impacted.

These data are consistent with prior literature that suggests a reduction in general medical and cancer-related appointments.^2,5,7,30 This study allows us to understand the magnitude of the impact across Missouri and southern Illinois. Future research exploring whether those with higher educational attainment were more likely to cancel appointments because they were more likely to have better access to scheduling future appointments could further elucidate the extent of educational disparities in healthcare access.

These cross-sectional data cannot infer causality however, many of the correlates of interest (e.g., race, educational attainment) pre-date COVID-19 and the need to consider postponing clinical care. Thus, it is unlikely these results are subject to reverse causation. Also, those excluded due to missing data were more likely to be uninsured. If uninsured persons were also more likely to have postponed appointments, this could potentially bias results about care disruptions by insurance status towards the null and underestimating the impact.

Despite these limitations, this is a significant study that can improve our understanding of COVID-19 impacts on cancer prevention and control and offer specific insights into the region. In our data, those with higher education were more likely to postpone care. This indicates that any trends seen in increasing late-stage diagnosis might occur across socioeconomic categories. Additionally, while Black and White people of higher educational attainment both had increased odds of care disruption, having a scheduled telehealth visit was significantly associated with higher odds of care disruption only for White residents. This suggests that while White people were canceling in-person care, this care may have been substituted with telehealth appointments. Many of these screenings cannot be done virtually, yet this warrants further investigation to understand if care disruption does not always equate to being disconnected from healthcare for some and the subsequent impact on racial disparities in cancer care.