Background: Preoperative chemoradiotherapy is currently the standard of care for patients with distal rectal cancer. With intensity modulated radiation therapy (IMRT), more conformal doses of radiation can be delivered to tumor while sparing normal tissue. It is our intent to present updated data showing five-year follow up on patients treated concurrently with chemotherapy and IMRT reporting on local control, overall survival, and toxicity Methods: From April 2007 to February of 2014 a study of 16 patients at Lankenau Medical Center were treated for distal rectal cancer using IMRT. Patients staged from T1- T3 N0M0 received 5580 cGy to the pelvis using a nine field plan to tumor, involved and uninvolved lymph nodes. The median age was 64. All patients received 5FU based chemotherapy. All patients then went on to surgery 8-12 weeks following neoadjuvant therapy. All sixteen patients had undergone full thickness local excision via transanal endoscopic microsurgery (TEM). Chemotherapy (FOLFOX) was given to three patients adjuvently and one patient received xeloda. Patients were analyzed for local control (LC), median survival (MS), overall survival (OS), and toxicity. Results: The median follow-up was 47 months (range 3-72 months). Complete pathological response was achieved in five patients, and partial response was achieved in 11 pateints. Two patients had local recurrence (12.5%) and no patients progressed with distant metastatic disease. Both patients were re-irradiated and had undergone surgical salvage. All patients are currently no evidence of disease with an OS at six years of 100% with a MS of 42 months. Toxicity was acceptable with only one grade 2 toxicity (diarrhea), and two patients with grade 1 neutropenia. All patients were free of diversion and stoma. Conclusions: With six years of follow-up data, our experience has shown that neoadjuvant chemoradiotherapy with IMRT followed by TEM to treat rectal cancers in the distal third is well tolerated and effective. Local excision may provide excellent tumor control in properly chosen patients.