The predominant treatment for low- and intermediate-grade rectal cancer is still surgical radical resection, but treatment strategies have changed considerably in the last decade or so. In the past, the focus of preoperative diagnosis was on qualitative diagnosis, and the emphasis was on the radicality of surgery or whether anal preservation could be achieved. Currently, preoperative staging diagnosis of rectal cancer is valued, and treatment modalities and surgical procedures are selected for different stages to maximize patient benefits. In recent years, with the emphasis on the development and early detection of bowel cancer and the popularity of colonoscopy, the proportion of early rectal cancer detection has gradually increased, which provides good conditions for the improvement of treatment effect. Therefore, transanal local excision for early stage rectal cancer has become an important option, especially for elderly and frail patients who are at greater risk. Local excision includes transanal local excision and transanal endoscopic minimally invasive surgery. Since local recurrence after local excision is often advanced, local excision should be chosen with great caution and objective understanding of imaging findings, and the surgery should be limited to early stage low to middle rectal cancer with lymphatic metastasis. For patients with uncertain lymph node metastasis, younger age and longer expected survival time should take long-term treatment effect as the first consideration, and once the postoperative pathological examination results show the existence of high-risk factors, additional radical surgery should be performed in time. For this group of patients, the previous treatment policy is to first perform direct surgical resection of the primary tumor, and then add postoperative radiotherapy for patients with local lymph node metastasis or suspected radical resection according to the pathology report. Recent studies have shown that preoperative neoadjuvant radiotherapy has obvious advantages, which can significantly reduce the size of the tumor and increase the surgical resection rate. Many patients who cannot undergo radical surgery or anus preservation can not only undergo radical resection after neoadjuvant radiotherapy, but also can undergo anus preservation. In the past, most of the primary lesions would cause obstruction if they were not resected, and once the obstruction appeared, surgery was significantly worse than early surgery in terms of surgical risk and tumor resection rate, and the presence of primary lesions was often accompanied by symptoms such as bleeding, increased number of stools, urgent stools and tumor depletion. Therefore, it is generally recommended to remove the primary lesion as soon as possible after clear diagnosis, and then treat the metastatic lesion by other means such as chemotherapy. However, with the improvement of radiotherapy technology and the emergence of new chemotherapeutic drugs, especially targeted drugs, the control of local and metastatic lesions of rectal cancer has been significantly improved in recent years. For patients with extensive unresectable distant metastases, whether the primary foci need to be resected in one stage has attracted the consideration of clinicians. In conclusion, there are now more options for rectal cancer treatment. Instead of focusing on the radical resection of tumor and whether to preserve anus, reasonable treatment strategies should be selected based on accurate preoperative staging to maximize the benefits to patients, avoiding both the long-term effects of inadequate treatment and the decline in survival quality caused by overtreatment.