The role of local therapy for curative intent treatment of patients with favorable rectal cancer is highly controversial. Appropriate staging is essential to exclude patients with tumors that penetrate the rectal wall or spread to mesorectal lymph nodes. Studies on the outcome after local excision for rectal cancer are frequently heterogeneous, and results vary significantly. Recent studies indicate that local excision for early rectal cancer has a high rate of recurrence. Based on these results, together with our own experience, we restrict the use of curative intent local excision to only a few highly selected patients.