Background: Rural cancer care in the United States has unique challenges from variable access to care. This study examined differences in time to first treatment (TTT), a surrogate for access, and predictors of overall survival (OS) between rural and non-rural colorectal cancer (CRC) patients. Methods: Patients with stage I-III CRC from 2004-2012 in the National Cancer Database of Commission on Cancer (CoC)-accredited facilities were included and categorized into rural and non-rural groups. Differences in demographic, disease characteristics, socioeconomic (SE) factors and TTT (< 4 weeks, 4-8 weeks and > 8 weeks) between rural and non-rural patients were assessed by Chi-square test. The effect of demographics, SE factors, and TTT on OS were assessed using Cox models. Results: The study population comprised 605,913, 11,649 (2%) of whom were rural. Compared to non-rural patients, rural patients were more likely to be age > 65, male, Caucasian, receive care at non-academic centers, have government insurance, have lower income and less education (p<0.0001 for all). Significant demographic and SE differences are shown in Table. Rural patients had similar mean TTT compared to non-rural patients (2.76 vs. 2.84 weeks, p = 0.35). Slightly more rural patients had TTT < 4 weeks (77% vs. 75%, p <0.0001). Shorter TTT (both <4 weeks vs. 8 weeks and 4-8 weeks vs. > 8 weeks) was associated with improved OS (HR: 0.87, 95% CI: 0.85-0.89, p<0.0001 and HR: 0.74, 95% CI: 0.73-0.76, p<0.0001, respectively). After adjusting for demographic, disease and SE factors, rural status was associated with modestly better OS compared to non-rural status (HR: 0.96, 95% CI: 0.92-0.99, p=0.006). Conclusions: Despite several adverse demographic and socioeconomic factors, rural CRC patients had modestly better OS compared to non-rural patients. Rural and non-rural CRC patients had similar TTT in this cohort. These data suggest the comprehensive cancer care delivered by CoC-accredited practices is associated with rapid TTT and improved OS in rural CRC patients. It is unclear whether our data apply to non-CoC-accredited facilities in rural United States.