The major goals in the treatment of patients with rectal cancer are overall cure, maximizing local control, and maintaining quality of life. Quality of life issues include avoidance of a permanent stoma and maintaining adequate bowel, sexual, and urinary function. Optimizing the surgical technique with a more selective application of adjuvant therapy will meet these goals. This article describes the likely explanations for local and distant recurrence and delineates current clinical trials of adjuvant therapy directed toward minimizing failure despite potentially curative surgical resection.