Background: Rural cancer patients face limited access to care due to greater travel distance and lack of specialty cancer care. Little is known about the intersection of rurality with well-documented racial disparities in colon cancer treatment and outcomes. Methods: We used fee-for-service Medicare claims to study patients age 65+ diagnosed with incident colon cancer without evidence of metastases who underwent cancer-directed surgery between 04/01/2016 and 09/30/2018. The primary exposure was rurality of patient’s residence categorized as metropolitan (metro), micropolitan, and small town/rural. Outcomes were non-elective surgery (emergency department visit or transfer within 2 days of surgery), receipt of minimally invasive surgery (laparoscopic or robotic), 90-day surgical complications, and 90-day mortality. Logistic regression adjusted for patient demographics, cancer side (right vs left), comorbidities, and Area Deprivation Index. We assessed effect modification by race/ethnicity. Results: Of 57,710 patients with incident non-metastatic colon cancer, 37,691 (65%) underwent surgery. In this surgical cohort, small town/rural and micropolitan residents were more likely to be older, white, and Medicare-Medicaid dual-eligible than metro residents. After risk adjustment, patients in small town/rural areas had higher odds of non-elective surgery (OR=1.24, 95% CI:1.13-1.36) and lower odds of minimally invasive surgery (OR=0.75, 95% CI:0.71-0.80) than patients living in metro areas. Similar results were seen for micropolitan areas. The association between rurality and 90-day outcomes differed by race/ethnicity (p-interaction=0.001 for surgical complications and mortality, see Table). Hispanics and other races had higher odds of 90-day surgical complications in non-metro versus metro areas but there was no notable difference for white patients. Likewise, compared to metro areas, racial/ethnic minorities had higher odds of 90-day mortality in small town/rural areas but white patients had lower odds. Conclusions: Small town/rural-residing Medicare beneficiaries undergoing surgery for non-metastatic colon cancer were less likely to receive optimal surgical management and worse outcomes, especially among non-white patients. The compounded effect of sociodemographic factors should be further studied to develop targeted policies and improve care for rural cancer patients.