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 the cancer care team determines that TNT is the best approach, most or all of the cancer therapy will be _neoadjuvant_, meaning that it is delivered _before_ [surgery](Surgery.md). TNT requires several cancer experts including surgical, medical and radiation oncologists working together to plan and deliver the treatment. Source: [Total Neoadjuvant Therapy for Rectal Cancer](https://www.roswellpark.org/cancer/colorectal/treatment/total-neoadjuvant-therapy-rectal-cancer) Standard TNT seems to be combined chemo-rad therapy (chemoRT, or CRT), then full systemic [chemotherapy](Chemotherapy.md), then [surgery](Surgery.md), and then possibly post-operative [chemotherapy](Chemotherapy.md). But there seems to be some newer TNT approaches emerging, one from a Polish study: >The Polish Colorectal Study Group recently presented data from a randomized controlled trial demonstrating that the use of short-course RT followed by [chemotherapy](Chemotherapy.md) in a TNT approach was associated with an improved 3-year overall survival compared with just traditional neoadjuvant chemoRT and adjuvant chemotherapy.10 >Source: [Is Total Neoadjuvant Therapy in Rectal Cancer Ready for Prime Time?](https://dailynews.ascopubs.org/do/10.1200/adn.18.190005/full/) This short course RT followed by [chemotherapy](Chemotherapy.md) (with no CRT) seems like what they've got me on now. This is a really good overview interview with a doctor from the Cleveland Clinic on TNT: [Total Neoadjuvant Therapy with Nonoperative Management in Rectal Cancer – Consult QD](https://consultqd.clevelandclinic.org/total-neoadjuvant-therapy-with-nonoperative-management-in-rectal-cancer/) ## Overview of rectal cancer standards & TNT Current rectal cancer standards include neoadjuvant chemoradiotherapy (CRT), which means chemo-rad treatments *before* surgery. Adjuvant [chemotherapy](Chemotherapy.md) (ChT) after CRT and surgery is also common. But the results from that seem less good, and people have a harder time keeping up with it after [surgery](Surgery.md). So they are moving that post-surgery chemo treatment up front. Then on the [surgery](Surgery.md) front, there is total mesorectal excision [TME](../attachments/Pasted%20image%2020220827172403.png). This is the current standard of care in surgical removal of the tumor. So wrapping all these three things up is TNT. This is a newer, comprehensive trimodality approach with neoadjuvant chemoradiotherapy, total mesorectal excision (TME), and systemic chemotherapy. It is recommended for medically operable patients with nonmetastatic, locally advanced rectal cancer (LARC). Source of much of the above: [Total neoadjuvant therapy for rectal cancer: An emerging option - PubMed](https://pubmed.ncbi.nlm.nih.gov/28295220/) From a BCCA page on chemotherapy drugs and TNT:  [Total Neoadjuvant Therapy (TNT) versus Standard Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer: A Systematic Review and Meta-Analysis - PubMed](https://pubmed.ncbi.nlm.nih.gov/33987952/) A clinical trial to study traditional Chinese medicine with fluoropyrimidine and oxaliplatin-based [chemotherapy](Chemotherapy.md), which is what I will likely be doing as part of TNT: [Efficacy of Chinese herbal injections combined with fluoropy... : Medicine](https://journals.lww.com/md-journal/Fulltext/2020/12240/Efficacy_of_Chinese_herbal_injections_combined.15.aspx)