Aim: The aim was to study the effects of the introduction of TME surgery and pre-operative radiotherapy on overall survival (OS) by comparing patients treated in the period before (1990-1995), during (1996-1999) and after (2000-2002) the TME trial. Patients and methods: Patients diagnosed with rectal carcinoma in the region of Comprehensive Cancer Centres South and West were used (n = 3179). Results: Five-year OS was, respectively, 56%, 62% and 65% in the pre-trial, trial and post-trial periods (p < 0.001). Pre-operative RT was increasingly used over time and significantly related to OS in the post-trial period (p = 0.002), but not in the pre-trial and trial periods. Conclusions: Population-based OS improved markedly since the introduction of TME surgery. With standardised TME surgery, pre-operative RT improved OS, whereas withholding pre-operative RT was associated with a poorer prognosis. The present study supports that pre-operative RT was correctly introduced as a standard treatment before TME surgery in our national guideline. (C) 2008 Elsevier Ltd. All rights reserved.