The conventional therapy for locally advanced rectal cancer involves surgery and adjuvant therapy. The standard adjuvant therapy is combined modality treatment, including 5-fluorouracil chemotherapy and radiation. The standard of care in terms of timing of adjuvant therapy, whether pre- or postoperative, continues to evolve, and potential advantages and disadvantages exist for both neoadjuvant and adjuvant combined modality therapy. Newer modalities of assessment, such as endoscopic ultrasound, have had an impact on more accurate staging of locally advanced rectal cancer, thus impacting the choice of therapy. Continued emphasis on improving survival, decreasing local recurrence, and minimizing treatment toxicity to improve quality of life are the goals of ongoing research in the field of rectal cancer.