Background National Comprehensive Cancer Network guidelines recommend screening new cancer patients for distress as its presence has been shown to negatively impact quality of life and clinical outcomes. Little is known about the specific causes of distress in patients undergoing curative resection for colorectal cancer. Surgeons are often the first physicians to have in-depth conversations with patients about a new diagnosis of colorectal cancer; therefore it is imperative that surgeons understand how patients cope with the distress of a diagnosis and what role a surgeon should to play in managing distress. Understanding how tools these patients use to cope can also help determine us to understand what additional techniques could be used and how the surgeon’s team can be involved. We sought to characterize the distress these patients face during treatment and how patients cope while undergoing surgery. Methods We performed in-depth qualitative interviews to explore the sources of distress among patients with non-metastatic colorectal cancer during treatment. We used purposive sampling to conduct semi-structured open-ended interviews with patients who had undergone, or were about to undergo, curative resection for colorectal cancer. Key questions addressed patient’s emotions in response to the cancer diagnosis and the surgical experience, as well as their beliefs regarding the role of the surgeon in helping them cope. Interviews were conducted until saturation was reached (N=20). Validated patient-reported outcomes were assessed measuring level of independence, symptoms of anxiety and depression, quality of life, and satisfaction with surgical care. Each interview was transcribed and coded independently by 3 reviewers. The analysis was refined iteratively with all changes to codes resolved by consensus. We used grounded theory to allow themes to arise from the data. Results The mean age of participants was 63 years (+14) and 70% were women. 70% self-identified as White, 15% as Black, and 10% as Hispanic. 75% patients underwent surgery within 5 months of the interview, while 25% were receiving neo-adjuvant chemoradiation and were about to undergo curative resection. No patients carried a prior diagnosis of anxiety or depression; 2 patients had an abnormal screening score on the Hospital and Anxiety Depression Scale. Four main categories of sources of distress arose from all interviewed patients: 1) preoperative sources of distress; 2) sources of distress during surgery and in-hospital recovery; 3) sources of distress during post-discharge recovery; and 4) sources of distress that occurred throughout the surgical experience (preoperative, in-hospital recovery, and post-discharge recovery). Three major themes emerged from the data that described how patients with colorectal cancer cope throughout the surgical experience: 1) patient strategies for coping; 2) surgeons role helping patients cope with distress; and 3) role of social support network. Conclusions The results of this study are important for colorectal surgeons to consider when caring for patients with a new colorectal cancer diagnosis. All colorectal cancer patients undergoing surgery reported experiencing distress at some point during their treatment course, independent of the presence of a clinical anxiety or depressive disorder. A patient-centered approach to a new colorectal cancer patient should include a multi-pronged approach to screen patients for distress, identify and strengthen a patient’s own coping strategies, facilitate a strong social support network, and provide patients with the option to obtain further support from the surgeon’s office. This final component should only be offered if patients are noted to have a deficit in their own coping strategies or the presence of a strong social support network. Next steps include the development of a patient-specific algorithm to help colorectal cancer patients cope with the surgical experience and development of a brief psychosocial intervention to be employed in patients with the greatest need.