Purpose: Primary local excision (PLE) for early rectal cancers is associated with decreased surgical morbidity and mortality compared with major resection (MR). However, it is thought to be associated with poorer oncological outcomes. There is a paucity of data regarding PLE within the Australasian population. We present comparative post-operative and survival outcomes for stage 1 rectal cancers treated with PLE or MR from three Western Australian hospitals. Methods: A retrospective analysis was performed on a prospectively maintained database of patients undergoing PLE or MR for stage 1 rectal cancers between February 1996 and May 2019. Results: Of the 533 patients, 81 underwent PLE. Median post-operative admission was shorter for those undergoing PLE, with no significant difference in post-operative complication rate. Five-year overall survival was greater following MR (89.6% CI 86.1–92.3) compared with PLE (84.6% CI 73.8–91.2; p = 0.0003). There was no significant difference in 5-year cancer-specific survival (MR, 94.4% CI 91.5–96.3; PLE, 95.3% CI 86.0–98.5; p = 0.98) or 5-year disease-free survival (MR, 92.3% CI 89.1–94.7; PLE, 89.1% CI 78.5–94.7; p = 0.36). Local excision provided poorer local tumour control with an inferior 5-year local recurrence rate (MR, 2.16% CI 1.08–4.28; PLE, 10.9% CI 5.30–21.6; p = 0.0002). After controlling for confounders, PLE was significantly associated with worse local recurrence but did not significantly impact overall survival, cancer-specific survival, overall recurrence, or metastatic recurrence. Conclusion: Local excision of early rectal cancer remains a viable alternative, in those unwilling or unable to undergo MR. Patients should be informed that while PLE is associated with poorer local pelvic control, this does not translate to worse survival.