INTRODUCTION: Colorectal cancer (CRC) incidence and mortality before 50 have been rising alarmingly in the recent decades. METHODS: Using a cohort of 10,000 patients, this study investigates the clinical, mutational, and co-mutational features of CRC in early-onset (EOCRC, <
50 years) compared to late-onset (LOCRC, ≥ 50 years). RESULTS: EOCRC was associated with a higher prevalence of Asian and Hispanic patients, rectal or left-sided tumors (72% vs. 59%), and advanced-stage disease. Molecular analyses revealed differences in mutation patterns, with EOCRC having higher frequencies of CONCLUSION: This study highlights the significance of age-specific molecular profiling, offering insights into the unique biology of EOCRC and potential clinical applications.