OBJECTIVES: To examine the proportion of elderly colorectal cancer (CRC) patients receiving guideline-concordant surveillance care and analyze predictors of guideline concordance using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. METHODS: In this retrospective observational cohort study, early-stage CRC patients diagnosed between 2004 and 2008 and aged ≥66 years who survived at least 3 years were selected for study inclusion. Patients who received surveillance care concordant with the 2013 American Society of Clinical Oncology (ASCO) guidelines were identified. Guidelines were considered met if patients received ≥2 office visits for history/physical examination annually, ≥2 carcinoembryonic antigen (CEA) tests annually, ≥1 CT scan annually, and ≥1 colonoscopy in a three-year period. Multivariable logistic regression analysis was performed to examine predictors of guideline-concordant surveillance care.  RESULTS: A total of 23,598 patients (mean age: 77 years) met the inclusion criteria. Overall, only 8.5% received guideline-concordant surveillance care during the study period. Individually, recommendation for office visits, CEA tests, CT scans, and colonoscopy were met by 82%, 23%, 15%, and 73% of patients, respectively. Guideline concordance was significantly higher among patients with regional-stage disease versus local-stage disease (15% vs. 4%, p<0.0001). Based on the multivariable analysis, predictors of lower concordance included older age groups (75-84 vs. 66-74 years, odds ratio [OR]: 0.53, 95% confidence interval [CI]: 0.48-0.59) and black race (vs. white, OR: 0.63, 95%CI: 0.51-0.78). Patients with regional-stage disease and larger tumor sizes were associated with higher levels of concordance with recommended surveillance care guidelines. CONCLUSIONS: Concordance with the current follow-up care and surveillance protocol for patients with early-stage CRC was substantially low, with older age, black race, and local-stage disease being the significant predictors of low concordance. Further research assessing barriers to access to guideline-recommended survivorship care is crucial to improve long-term outcomes among these patients.