Over the past two decades, the incidence of colorectal cancer among adults < 50 years of age (i.e., early-onset CRC) has been alarmingly and steadily increasing. Despite these increases, survivorship care has evolved slowly and remains poorly informed and of suboptimal quality. Patients with early-onset CRC are particularly vulnerable to suboptimal care given the disease is more often diagnosed in racial and ethnic minorities, and at a stage in life when financial instability and being medically underinsured or uninsured are more common. Thus, there is a critical need to design a model of survivorship care that aligns: 1) the intensity of surveillance with actual risk of recurrence; and 2) the provision of care services with need. Stratified survivorship care pathways provide an opportunity to deliver patient-centered, high-quality care that is appropriately tailored to individual needs. However, these pathways currently do not exist for patients with early-onset CRC, which is in part to the lack of population-based estimates of recurrence that can guide surveillance approaches and the dearth of knowledge regarding these patients’ unique survivorship care burdens and needs. In this proposal, we will partner with three SEER registries in Georgia, Kentucky and Los Angeles to apply a new methodology and identify patterns of recurrence among patients with stage I-III early-onset CRC to generate population-level estimates of risk of recurrence and examine clinical and sociodemographic factors associated with recurrence risk (Aim 1). We will then survey a contemporary and diverse SEER-based cohort of patients diagnosed with early-onset CRC to assess patients’ receipt of surveillance and self-reported survivorship care needs across multiple domains (e.g., physical symptoms, financial issues, family planning) (Aim 2). Finally, informed by findings from Aims 1 and 2, we will develop a stratified survivorship care framework and care pathways with a multi-disciplinary Advisory Panel. We will then engage patients, caregivers, and clinician stakeholders in a consensus panel using the RAND/UCLA Appropriateness Method to refine and finalize the stratified survivorship care framework and care pathways. We will then assess the acceptability, appropriateness, and feasibility among the stakeholders. This study will yield much-needed population-based estimates of recurrence risk, surveillance intensity, and survivorship care needs, and generate stratified survivorship care pathways for this rapidly growing population of cancer survivors. The findings have the potential to meaningfully improve the quality of survivorship care for patients with early-onset CRC, and advance the science of stratified survivorship care delivery for other cancers more broadly.