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Background: There is a paucity of recent literature investigating the sole effect of income level on the treatment and survival of patients with rectal cancer. Methods: We analyzed all cases of rectal cancer in the Rectal Cancer PUF of the NCDB from 2010 to 2020. We utilized the Median Income Quartiles 2016–2020 to define our income levels. The two lower quartiles were combined to create a lower income group, with the upper two quartiles creating the higher income group. The total cohort included 201,329 patients, with 116,843 and 84,486 in the higher and lower income groups, respectively. Results: Lower income patients were more often black (17 % vs 6 %), lived farther from the nearest hospital (33.5 miles vs 25.7 miles) despite being more likely to live in urban areas (25 % vs 7 %), and had lower levels of private insurance (36 % vs 49 %). They underwent more APRs (17 % vs 14 %) and had a 13 % higher chance of undergoing an open operation (OR 1.13, CI 1.09–1.17). Higher income patients had a 12 % reduction in 90-day (OR 0.88, 95 % CI 0.82–0.96) and overall mortality (OR 0.88, 95 % CI 0.86–0.89). Conclusions: Clinicians should be aware that lower income patients are often faced with unique challenges that may impact care delivery.