Background: Cancer mortality rates remain substantially higher among rural populations. Rural-urban disparities in cancer outcomes are partly associated with care delivery challenges in rural areas, and the COVID-19 pandemic may have exacerbated these disparities. Care coordination (CC) is a critical component of patient-centered care; yet, rural patients experience significant CC-related challenges. In this study, we examined patient-reports of CC and time to treatment initiation (TTI) among rural patients with early-stage cancer. Methods: We conducted a cross-sectional survey with 51 patients with early-stage (I-III) cancer receiving active treatment at rural oncology practices between May 2021 and June 2022. Rural was defined using RUCA. Enrolled patients completed the background questionnaire and the Care Coordination Instrument (CCI). A validated instrument, the 29-item CCI assesses overall patient perceptions of CC and three domains of CC (Communication, Navigation, Operational). Items are rated on a 4-point Likert-scale. Data for the urban cohort were derived from historical data. General linear models (GLMs) were used to compare CCI scores between rural and urban patients. Results: The mean age of rural patients was 58.5 (range 24.0-84.0), and 64.7% were female. GI (39.2%) and breast (33.3%) were the most common cancer types. Median time from diagnosis to treatment initiation for rural patients was 61.0 days (IQR: 30.0-65.8), significantly longer compared to the pre-pandemic state registry data. 21.6% of rural patients reported delays in active treatment. Overall, there were no rural-urban differences on the overall perception of CC (p> .05). However, rural patients reported significantly lower Communication scores (p = .027). After adjusting for the effects of covariates, rural-urban differences on Communication remained significant (p = .016). Item-level analyses revealed significant rural-urban differences in specific aspects of CC (e.g., physician-patient communication). CCI scores were not associated with TTI. Conclusions: Our findings indicate that rural patients with early-stage cancer experienced significant delays in treatment initiation during the pandemic, and there were notable differences in Communication aspects of CC between rural and urban patients. Interventions to improve TTI among rural patients are urgently needed to prevent potentially further exacerbating cancer health disparities.