OBJECTIVES: To examine colorectal cancer (CRC) treatment patterns in the initial phase-of-care, the extent of receipt of minimally-appropriate CRC-treatment (MACT), the associated survival in a three-year period following a CRC-diagnosis in Medicare beneficiaries diagnosed with CRC from a rural setting, and to compare these findings with “national” estimates. METHODS: A population-based retrospective cohort-study was conducted with data from fee-for-service Medicare beneficiaries aged ≥66 years diagnosed with CRC between 2003-2006 identified from the West Virginia Cancer Registry (WVCR)-Medicare linked database (n=2,119).  A comparative “national” cohort was identified from Surveillance, Epidemiology, and End Results (SEER)-Medicare (n=38,168).  CRC-treatment received was ascertained from beneficiaries’ Medicare claims by following them for 12-months from their CRC-diagnosis date or until death.  Receipt of MACT was defined based on National Cancer Institute CRC-treatment guidelines.  All-cause and CRC-specific mortality in the 36-month period following CRC-diagnosis were examined after accounting for selection bias using inverse probability treatment weights. RESULTS: Although a higher proportion of beneficiaries from WVCR-Medicare were diagnosed in the earlier stages of CRC (when it can still be treated effectively) as compared to their SEER-Medicare counterparts, they had poorer CRC-survivorship with adjusted hazards ratio (AHR)=1.26;95%CI=[1.20,1.32]. This poorer survivorship may be due to a lower-likelihood (adjusted odds ratios (AOR)=0.85;95%CI=[0.76,0.96]) of beneficiaries from WVCR-Medicare of  receiving MACT as compared to their “national” counterparts.  Differences in usage of CRC-surgery, chemotherapy and radiation were also observed in the two populations.  Those from WVCR-Medicare were less likely to receive any type of CRC-surgery with AOR=0.82;95%CI=[0.73,0.93]. CONCLUSIONS: This study highlights the need for an increased emphasis on adoption and adherence to accepted surgical and adjuvant CRC-treatment guidelines, and improving access to CRC-care for those from rural-settings.  Further research needs to be conducted to determine if similar rural-urban differences in receipt of MACT exist in the elderly in other rural-areas of the nation.