BACKGROUND: The purpose of this study was to describe management and outcome in patients with locally recurrent rectal cancer based on data from the Norwegian Colorectal Cancer Registry. METHODS: This was a prospective national cohort study of 577 patients with local recurrence after major resection (R0/R1) for rectal cancer between November 1993 and December 2001 (initial cohort of 4504 patients). RESULTS: Of the 577 patients, 185 (32.1 per cent) had curative resections (R0/R1), 203 (35.2 per cent) had palliative radiotherapy with or without palliative surgery and chemotherapy, and 189 (32.8 per cent) received no treatment at all or only palliative surgery or chemotherapy. The overall 5-year survival rate was 14.9 per cent. Ninety-seven patients had an R0 resection, and 88 had an R1 resection, with 5-year overall survival of 55 and 20 per cent respectively. This outcome reflected surgical treatment in 33 different hospitals. Some 274 patients (47.5 per cent) had metastases. The 5-year survival rate after R0 resection was 62 per cent in patients without metastases. CONCLUSION: Obtaining an R0 resection is the most important prognostic factor in treating recurrent rectal cancer.