Objective: Guidelines recommend that patients with non-metastatic rectal cancer receive surgery and adjuvant chemotherapy and/or radiation therapy (XRT) after surgery (especially if stage Il and III). Studies reported that 90% of stage Il and III patients received surgery, and 70% received adjuvant treatment. In states where socioeconomics and limited medical resources may hinder treatment, cancer care is understudied. The objective is to describe initiation and completion of rectal cancer treatment in Alabama. Methods: Medicare claims were obtained for 675 stage I to III rectal cancer patients diagnosed in 1999-2003, enrolled in fee-for-service Medicare, and with at least 9 months of follow-up. Logistic regressions were used to identify significant differences by sex, age, and race in the likelihood of initiating treatment and receiving an incomplete course of chemotherapy or XRT (≤120 days of chemotherapy and ≤28 days of XRT). Results: Overall, 90% received surgery, of which 43% received some adjuvant treatment. Among stage Il to III patients, 58.8% received adjuvant treatment. Except for patients aged 75 years and greater being less likely to start chemotherapy, there were no significant differences in initiation by age, sex, and race. Depending on concurrent administration of chemotherapy and XRT, 29% to 35% received incomplete chemotherapy, and 16% to 23% incomplete XRT. Women were more likely to have incomplete chemotherapy than men. Conclusions: Adjuvant treatment was less than reported in previous studies. Treatment initiation and completion did not differ across demographic factors. Future studies should explore reasons why older rectal cancer patients in Alabama are less likely to receive recommended treatment.