The burden of colorectal cancer (CRC) morbidity and mortality falls largely on the elderly, who make up more than 70% of CRC patients. Recent evidence from pooled analyses suggests that both adjuvant and palliative chemotherapy are as efficacious in fit older patients as in younger patients. Although severe hematologic toxicity is increased in older age groups treated with chemotherapy, this does not appear to increase the risk of other severe adverse events. Little evidence is available to guide radiotherapy decisions in older rectal cancer patients or chemotherapy decisions in older patients who are less fit than patients enrolled in clinical trials who are typically more robust. Despite its apparent utility in older patients, chemotherapy use declines rapidly with age. This decline likely results from a combination of appropriate concern for safety and simple failure to consider older patients as suitable candidates for treatment. Much more research is needed to identify optimal strategies for the treatment of less fit older patients with CRC.