Previous data from the National Cancer Database (NCBD) showed increasing rates of transanal local excision for early rectal cancer despite a lack of evidence supporting its oncologic adequacy. The aim of this study is to update national trends, compare overall survival, and determine factors associated with survival in patients with stage I rectal cancer. Survival of 15, 149 patients with stage I rectal adenocarcinoma were examined retrospectively from 2004-2012. The rate of local excision over this time period was sustained at 22% (20.88 - 24.9%; p = 0.077). Five-year overall survival (OS) after transanal local excision was less than transabdominal standard resection (76.6% vs. 80.7%; p 4 cm, low volume centers, uninsured patients and increasing comorbidities. This is the first study of national data showing sustained use of transanal local excision over the past decade. Local excision has a lower 5-year OS compared to transabdominal standard resection. Transanal excision of early rectal cancer should be offered to select patients only after careful consideration of risk factors balanced against the decrease in overall survival.