BACKGROUND: The number of cases of rectal cancer in our older cohort is expected to rise with our ageing population. In this study, we analysed patterns in treatment and the long-term outcomes of patients older than 80 years with rectal cancer across a health district. METHODS: All cases of rectal cancer managed at the Illawarra Cancer Care Centre, Australia between 2006 and 2018 were analysed from a prospectively maintained database. Patients were stratified into three age groups: ≤65 years, 66-79 years and ≥80 years of age. The clinicopathological characteristics, operative and non-operative treatment approach and survival outcomes of the three groups were compared. RESULTS: Six hundred and ninety-nine patients with rectal cancer were managed, of which 118 (17%) were aged 80 and above. Patients above 80 were less likely to undergo surgery (71% vs. 90%, < 0.001) or receive adjuvant/neoadjuvant chemoradiotherapy ( < 0.05). Of those that underwent surgical resection, their tumours were on average larger (36.5 vs. 31.5 mm, = 0.019) and 18 mm closer the anal verge ( = 0.001). On Kaplan-Meier analysis, those above 80 had poorer cancer-specific survival when compared to their younger counterparts ( = 0.032), but this difference was no longer apparent after the first year ( = 0.381). CONCLUSION: Patients above the age of 80 with rectal cancer exhibit poorer cancer-specific survival, which is accounted for in the first year after diagnosis. Priority should be made to optimise care during this period. There is a need for further research to establish the role of chemoradiotherapy in this population, which appears to be underutilised.