OBJECTIVE: Whether resection of the primary tumour is of benefit to patients with incurable rectal cancer (RC) remains a matter of debate. In this study we analyse prospectively recorded data from a national cohort. METHOD: Among 4831 patients diagnosed with RC between 1997 and 2001, 838 (17%) patients were treated with palliative surgery. Patients were stratified according to disease stage, age and type of surgery. RESULTS: A significantly longer median survival, 12 (range 10-13) months, was observed in patients treated with resection of the primary tumour compared with 5 (range 4-6) months in patients treated with nonresective procedures (P /= 80 years of age). In patients over 80 years, survival was similar regardless of the treatment. Thirty-day mortality varied from 2.5% to 20%, according to age groups. CONCLUSION: The longer survival observed in patients with resection of the primary tumour may partly be explained by patient selection. Elderly patients (>/= 80 years) had a similar survival, irrespective of resection of the primary tumour or not. Careful consideration of the individual patient, extent of disease and treatment-related factors are important in decision-taking for palliative treatment for patients with advanced RC.