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 wasrurality 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 prior to 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. White rural patients had lower mortality than white urban patients, whereas black rural patients had higher mortality than black metro patients (see Table). Increasing area deprivation was associated with higher odds of non-elective surgery, surgical complications and mortality, and lower odds of minimally invasive surgery, even after adjusting for race and rurality. Conclusions: Small town/rural-residing Medicare beneficiaries undergoing surgery for non-metastatic colon cancer were less likely to receive optimal surgical management and had worse outcomes, especially among non-white patients. The compounded effect of rurality, race/ethnicity, and social deprivation should be incorporated in developing policies and interventions to improve care for rural cancer patients.