Purpose This study examined whether Aboriginal and Torres Strait Islander patients undergoing colorectal cancer resection at a regional tertiary centre had different peri operative and survival outcomes compared with non Indigenous patients. Methodology A retrospective cohort study of all patients undergoing colorectal cancer surgery at Cairns Hospital between 1 January 2019 and 18 November 2025 was performed. Demographic, clinicopathological and peri operative data were extracted from a prospectively maintained database. Overall survival (OS) and disease free survival (DFS) were calculated from date of surgery. Kaplan–Meier methods and log rank tests compared survival by Aboriginal and Torres Strait Islander status. Cox proportional hazards models estimated hazard ratios (HRs) adjusting for age, ASA score and AJCC stage (I–IV). Results Of 581 patients, 56 (9.6%) were Aboriginal and/or Torres Strait Islander. They were younger (mean 58.5 vs 67.5 years, P<0.001) but had higher operative risk (ASA ≥3: 76.8% vs 61.0%, P=0.03), were less often screen detected (10.7% vs 25.2%, P=0.02) and more frequently had stage III–IV disease (53.7% vs 38.1%, P=0.06) and metastatic presentation (20.4% vs 10.2%, P=0.04). Indigenous patients had more surgical (37.5% vs 21.3%, P=0.01) and medical (21.4% vs 10.1%, P=0.02) complications and longer median length of stay (8 vs 7 days, P=0.008). All cause mortality over follow up was higher in Indigenous patients (23.2% vs 11.2%, P=0.02). Kaplan–Meier 5 year OS was 64.1% in Indigenous patients and 82.5% in non Indigenous patients (log rank P=0.006; unadjusted HR 2.27, 95% CI 1.25–4.15, P=0.007). Five year DFS was 59.7% versus 79.3% (unadjusted HR 1.96, 95% CI 1.13–3.40, P=0.017). Conclusion In this regional cohort, Aboriginal and Torres Strait Islander patients presented with more advanced, higher risk colorectal cancer and experienced worse peri operative and unadjusted survival outcomes.