The basis of the current treatment of rectal cancer is a radical total mesorectal excision of the rectum, and although this provides excellent oncological control, it is associated with morbidity and functional problems in cancer survivors. Organ-preservation alternatives are local excision alone for very early tumors, chemoradiation followed by either local excision of a small tumor remnant or, when there is a complete clinical response, a nonoperative watch-and-wait approach. The functional advantage of these alternatives is clear, but there is some concern about the oncological risk. Although the available studies suggest that with adequate selection and follow-up this risk is small, the evidence is still weak. Because of patients' high interest in preserving quality of life, clinicians should cautiously move ahead and offer the option of organ preservation to patients in a controlled setting while awaiting further evidence.