Abstract: The treatment of locally advanced rectal cancer emphasizes multidisciplinary treatment, and the implementation of chemoradiation combined with total mesorectal excision (TME) has reduced local recurrence and prolonged overall survival, especially for lower/ middle rectal cancer. However, radiation therapy in locally advanced upper rectal adenocarcinoma management remains unclear. The definition of upper rectal cancer varies across different guidelines, and so do the recommendations on radiotherapy. At present, there is a lack of large-scale prospective randomized trials, and the results of previous studies are also contradictory. At the same time, the complications of pelvic radiotherapy cannot be avoided, therefore, how we make reasonable decisions about locally advanced high rectal cancer, how to decide based on the risk of recurrence, and whether radiotherapy can bring benefits all warrant further exploration. This review aims to summarize the questions and controversies of radiotherapy for high rectal cancer.