The management of distal rectal cancer is in evolution. Although abdominoperineal resection has been long regarded as the definitive treatment of distal rectal cancer, it is associated with significant morbidity--loss of anorectal function with a permanent colostomy and a high incidence of sexual and genitourinary dysfunction. To overcome these limitations, innovative efforts are underway studying the feasibility and efficacy of a variety of sphincter-preserving operations, usually in combination with radiation therapy and chemotherapy. Local excision procedures with adjuvant therapy represent one such treatment strategy that attempts to optimize local control and survival with preservation of sphincter integrity. This article summarizes the current role of local excision and postoperative irradiation and chemotherapy for patients with carcinoma of the rectum.