Purpose: Locally advanced rectal cancer is conventionally treated with neoadjuvant chemoradiotherapy (nCRT) and total mesorectal excision (TME). Patients who achieve a clinical complete response (cCR) to nCRT may be considered for organ preservation, though this remains contentious. This study investigated the relationship between cCR and pathological complete response (pCR) and their effects on oncological outcomes. Methodology: A retrospective cohort study was conducted on all rectal cancer patients treated with nCRT and TME at a tertiary hospital in Western Australia from 2004 to 2023. Patients with stage IV disease at diagnosis were excluded. Results: 327 patients were included, with a median age and BMI of 63 (IQR=15) and 27.5 (IQR=6.9), respectively. 5-year recurrence-free survival (RFS) was 69.3% (n=174), with a recurrence rate of 27.1% (n=68). pCR was observed in 16.2% (n=53) of cases. Of the 257 with clinical response data, 11.6% (n=38) had cCR while 68.9% (n=177) had partial cCR. Baseline characteristics, including initial staging, were comparable between groups. On univariate analysis, pCR was more strongly associated with 5-year RFS (92.5%, p<0.001) than cCR (83.3%, p=0.017) or partial cCR (61.5%, p=0.053). cCR was positively correlated with pCR (coefficient 0.38, p<0.001), though 44.7% (n=17) of patients with cCR did not have pCR. 58.9% (n=10) of these patients with occult residual disease required adjuvant chemotherapy. Interestingly, 12.4% (n=22) of those with only partial cCR ultimately had pCR. Conclusion: These results demonstrate that both cCR and pCR are strong predictors of RFS. However, they also highlight the limitations of utilising cCR alone to identify candidates for organ preservation.