Introduction – Colorectal cancer (CRC) is the second most common cancer among people aged 75 and older, but epidemiological data remain limited for the very elderly.Objective – To analyze trends over time in the incidence, metastatic status at diagnosis, initial treatments, and overall survival of CRC among the very elderly in Hérault.Methods – New cases of CRC diagnosed between 1988 and 2022 in people aged 75 and older were extracted from the Hérault Cancer Registry. Trends over time were analyzed using “joinpoint” regression by age group (75–79, 80–84, 85–89, ≥90). Results – Between 1988 and 2022, 9,162 individuals aged 75 and older were included. The incidence of colon cancer increased among those aged ≥75 (mean annual percentage change (MAPC): +1.4%), particularly among those aged ≥90 (MAPC: +4.1%). The incidence of rectal cancer was generally stable (MAPC: -0.3%), except for those aged ≥90 (MAPC: +4.0%). The proportion of cases with unknown metastatic status decreased over time, with a concomitant increase in distant metastases for colon cancer among those aged 85–89 (1996–2022: 10.0%–28.4%). The absence of active treatment increased over time for those aged 85 and older. Colon surgery decreased with age and over time between 2001 and 2022 (ages 75–79: 88.4%–74.8% vs. ages 85–89: 86.5%–65.7%). Net 3-year survival decreased with age (75–79 years: 66.9% vs. ≥90 years: 44%), with no significant improvement over time. Conclusion – The burden of colorectal cancer among the very elderly is increasing over time, underscoring the importance of strengthening epidemiological surveillance.