The standard surgical treatment for patients with potentially curable transmural and/or node-positive rectal cancer is a low anterior resection or abdominoperineal resection. There is increasing interest in the use of local excision and postoperative radiation therapy as primary therapy for selected rectal cancers. The limited data suggest that the approach of local excision and postoperative radiation therapy should be limited to patients with either T1 tumors with adverse pathologic factors or T2 tumors. Transmural tumors have a 24 percent local failure rate and are treated more effectively with standard surgery and preoperative or postoperative therapy. The results of local excision and postoperative radiation therapy are encouraging; however, more experience is needed to determine whether this approach ultimately has local control and survival rates similar to standard surgery.