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Patients who have an emergency operation for colorectal cancer have poorer long-term survival outcomes compared with elective patients. This study was designed to define the role of tumor pathology as a basis for the differences in survival outcomes.There were 1,537 elective and 286 emergency patients who had an operation for bowel cancer from 1997 to 2003. Tumor pathology and survival data collected prospectively for these patients were compared by modes of presentation.Excluding 30-day mortality, emergency patients as a whole had a five-year all-cause survival rate of 39.2 percent compared with 64.7 percent for elective patientsP< 0.0001 they also had more advanced Dukes C and D tumors (P< 0.0001). The rates of early T1 and T2 cancers were 4.7 percent for the emergency and 25 percent for the elective group. Emergency cases had more lymph node-positive patients and N2 patients (57.1vs.41.8 percent and 26.6vs.15.9 percent, respectively;P< 0.0001). Curatively resected emergency colon patients again had more advanced Dukes staged tumors (P< 0.0001) with a five-year survival rate of 51.6 percent compared with 75.6 percent for elective patientsP< 0.0001. On stage-for-stage analysis, the survival rates for curatively resected Dukes B and C colon cancers remained worse for emergency patients (P= 0.003 andP= 0.0002, respectively). Both emergency Dukes B and C groups had more T4 cases (21.5vs.10.6 percent;P= 0.017 and 26.4vs.15 percent;P= 0.016, respectively).Advanced tumor pathology is a basis for poor long-term survival in emergency colorectal cancers.