There are 3 widely used preoperative radiotherapy (RT) procedures in rectal cancer treatment including long course RT (LRT), short-course RT with delayed surgery (SRTW), and short-course RT with immediate surgery (SRT), without solid evidence to clarify which is best in terms of patient survival. We assessed 7766 rectal cancer patients from the Swedish Registry with adjusted confounding factors, showing that single RT procedure was suitable for all the patients. These RT procedures showed different effects on survival of the patients with various age and clinical stage, and therefore the more tailored RT strategy for rectal cancer patients should based on these predictive factors. Background: There are 3 widely used preoperative radiotherapy (RT) procedures in rectal cancer treatment including long-course RT (LRT), short-course RT with delayed surgery (SRTW), and short-course RT with immediate surgery (SRT). However, further evidence is required to determine which treatment option results in more optimal patient survival. Methods: This Swedish Colorectal Cancer Registry-based retrospective study of real-world data included 7766 stage I-III rectal cancer patients, of which 2982, 1089, 763, and 2932 patients received no RT (NRT), LRT, SRTW, and SRT, respectively. The Kaplan-Meier sur vival cur ve and Cox proportional hazard multivariate model were used to identify potential risk factors and to examine the independent association of RT with patient survival after adjusting for baseline confounding factors. Results: RT effects on survival differed by age and clinical T stage (cT) subgroups. Subsequent survival analysis by age and cT subgroups confirmed that patients >70 years old with cT4 benefited from any RT ( P < .001, NRT as reference) and equally from any RT ( P > .05 pairwise between RTs). In contrast, for cT3 patients =70 years, SRT and LRT were associated with better survival than SRTW ( P < .001). In patients < 70 years, LRT and SRTW had superior survival benefits in cT4 patients but inferior to SRT ( P < .001); SRT was the only effective treatment in the cT3N+ subgroup ( P = .032); patients with cT3N0 and < 70 years did not benefit from any RT. Conclusion: This study suggests that preoperative RT strategies may have varying effects on the survival of rectal cancer patients, depending on their age and clinical stage.