© 2016, Springer Science+Business Media New York. Since the adoption of total meso-rectal excision as the standard surgical approach for management of locally advanced rectal cancer, there has been a significant reduction in local recurrence. Neoadjuvant combined modality treatment with 5-fluorouracil-based chemotherapy and radiation has further improved local disease control and overall survival. Given the excellent survival obtained with this combined approach in T3N0 rectal cancer, there are concerns about the need for further exposure to chemotherapy with unproven benefit. We review the evidence for adjuvant chemotherapy in this setting and set out clinico-pathologic variables that may be useful for making a decision in favor of offering adjuvant therapy or observation.