Total Neoadjuvant Therapy for Rectal Cancer

New approach to treatment delivery offers potential for improved response, a less aggressive surgery and better quality of life.

What is total neoadjuvant therapy?

Total neoadjuvant therapy (TNT) is a treatment approach for locally advanced (stage II and III) rectal cancer that delivers cancer therapies in an alternative order. If your cancer care team determines that TNT is the best approach for you, most or all of your cancer therapy will be neoadjuvant, meaning that it is delivered before surgery.  

TNT requires several cancer experts including surgical, medical and radiation oncologists working together to plan and deliver the treatment, which includes:

  • Chemoradiation therapy. This type of treatment combines chemotherapy and radiation therapy, delivering both on the same day, typically 5 days a week for 5 to 6 weeks. Chemotherapy drugs help to sensitize cancer cells to the radiation, boosting the tumor-killing effect. Patients usually receive oral chemotherapy (pill form) prior to their radiation session each day of treatment. Some patients may receive their chemotherapy by infusion.
  • Chemotherapy. Then, an additional course of systemic chemotherapy, for approximately 4 months. Some patients have systemic chemotherapy first and then chemoradiation; others have chemoradiation first and then systemic chemotherapy.

Patients are then reassessed to determine how well the cancer responded and determine whether surgery is still necessary.

Benefits of total neoadjuvant therapy

The total neoadjuvant therapy approach offers several potential benefits:

  • Rectal tumors can be downsized so that a less aggressive, organ-sparing or sphincter-sparing surgery, may be possible, often sparing the patient from a permanent colostomy
  • Some patients have a complete response and may be able to take a watchful waiting approach and delay or avoid surgery altogether.
  • Upfront chemotherapy kills hidden metastatic disease that’s too small to be detected on scans, decreasing potential for disease recurrence.
  • Patients are better able to complete chemotherapy, without breaks in treatment, when treatment is delivered before surgery rather than after surgery, when patients are still healing from major surgery and adjusting to dramatic quality of life issues, such as living with an ostomy.