To compare the outcomes of W&W strategy in patients with locally advanced rectal cancer who achieve complete clinical response (cCR) after neoadjuvant therapy, with those pathological complete response (pCR) after total mesorectal excision (TME).This is a retrospective cohort analysis study. 1014 Patients of histologically proven with locally advanced rectal adenocarcinoma who had received neoadjuvant chemotherapy were eligible between January 2014 and December 2019. In whom we included patients who had cCR offered management with W&W strategy after completing long-course concurrent chemoradiotherapy or short-course sequential chemoradiotherapy, no distant metastases within 6 months after treatment, follow-up ≥1 year, and patients who did not have cCR but pCR after TME. The primary endpoints were 3-year and 5-year overall survival (OS), colostomy-free survival (CFS), disease-free survival (DFS), non-local regrowth disease-free survival (non- regrowth DFS), and organ preservation rate. For comparative analysis, we also derived one-to-one paired cohorts of W&W versus pCR using propensity-score matching (PSM).118 patients were enrolled, 49 of whom had cCR and managed by W&W, 69 had pCR, with a median follow-up period of 49.5 months (IQR 12.1-79.9). No difference in 3-year OS (97.1% vs 96.7%) and 5-year OS (93.8% vs 90.9%, P = 0.696) between W&W and pCR, but patients managed by W&W had significantly better 3-year and 5-year CFS (89.1% vs 43.5%, P < 0.0001). Six patients had local regrowth managed by W&W, while no local recurrence in the pCR group, which had better 3-year DFS (83.6% vs 97%) and 5-year DFS (83.6% vs 91.2%, P = 0.047). However, after salvage surgery, no significantly difference in 3-year non-regrowth DFS (95.9% vs 97%) and 5-year non-regrowth DFS (92.8% vs 97%, P = 0.407) between these two groups. In the PSM analysis (34 patients in each group), absolutely better CFS (90.1% vs 26.5%, P < 0.0001) were noted in the W&W group, but no differences in other survival between groups. A median interval of 17.5 weeks was observed for achieving cCR, while only 23.9% of patients achieved cCR within 5 to 12 weeks from radiation completion. Patients with short-course sequential chemoradiotherapy achieved cCR significantly later when compared with those with long-course concurrent chemoradiotherapy (19 vs 9.8 wk, P < 0.0001).The long-term outcomes of W&W strategy in patients with locally advanced rectal cancer were not inferior to that of those with pCR. 87.7% of patients had successful rectum preservation in W&W group, although patients may require a longer interval for efficacy assessment.