OBJECTIVES: Colorectal cancer (CRC) is the third leading cause of cancer mortality in the US with disparities in risk between rural and urban patients. The aim of the study was to: 1) describe the characteristics of hospital admissions, 2) compare the length of stay and in-hospital deaths in rural and urban West Virginia residents with a primary diagnosis of CRC. METHODS: Data from the Health Care Cost and Utilization Project, State Inpatient Database for the years 2003, 2005, 2006 and 2007 were used to perform analyses of all discharges with a primary diagnosis of CRC. Chi square tests compared categorical descriptive statistics between rural and urban cases. One-way ANOVA compared mean length of stay based on rural-urban category. RESULTS: Admissions for CRC as a primary diagnosis decreased constantly from 882 in 2003 to 787 in 2007. In-hospital deaths rose steadily from 5.1% in 2003 to 7% in 2006, but fell to 5.7% in 2007. Mean ages ranged between 69.6 years and 70.3 years and percentage of female admissions ranged between 53.1% and 55.2% over the four years. A greater proportion of patients from large metros (17.4%) died in-hospital compared to small metros (7.0%), micropolitan (4.4%) and rural (5.2%) areas (p<0.001). Leading primary payer was Medicare for all four locations. Rural patients had the shortest mean length of stay (9.0 days). The mean length of stay differed significantly between rural (9.0 days) and micropolitan (10.0 days) patients. CONCLUSIONS: Colorectal cancer provides a significant burden to the health care system in West Virginia. Unlike previously reported in certain other states and countries, a greater proportion of urban residents in West Virginia are dying in-hospital due to CRC. The reasons for these disparities go beyond demographic differences between rural-urban residents and need to be explored.