Objective: To determine whether an association exists between distance from radiotherapy facilities and survival outcomes of people diagnosed with rectal cancer. Design and setting: Descriptive population-based study using data from the Queensland Cancer Registry. Patients: All patients aged 20-79 years (n = 6848) diagnosed with invasive rectal cancer between 1 January 1996 and 31 December 2006. Main outcome measure: Cause-specific survival. Results: The 5-year cause-specific survival was 62% (95% CI, 61%-64%); it was strongly influenced by stage at diagnosis (American Joint Committee on Cancer, Stages I-IV), ranging from 86% (Stage I) to 9% (Stage IV). After adjusting for age, sex, and stage at diagnosis, patients who lived 100-199 km, 200-399 km and 400 km or more from a radiotherapy facility were 16%, 30%, and 25%, respectively, more likely to die from rectal cancer than patients living within 50 km of such a facility. On average, there was a 6% increase in mortality risk (95% CI, 3%-8%; P < 0.001) for each 100 km increment in distance from the nearest radiotherapy facility. Shared frailty models showed that this association persisted after adjusting for the correlation between individual cancer patients living in the same remoteness or area-level socioeconomic status categories. Conclusions: While centralisation of cancer treatment services has merit, our study provides evidence of a shorter survival for people with rectal cancer who live relatively far from radiotherapy facilities. It remains a priority to develop and implement policy, cultural and clinical measures to reduce the burden faced by rural and remote patients with rectal cancer.