How would you sequence treatment (chemo and chemoRT) for a patient with a very symptomatic locally advanced rectal adenocarcinoma, MSS, with involved pelvic nodes and a mass abutting the sphincter, with no distant disease on CT but marked elevation in CEA above 300?

A pretreatment CEA level above 300 ng/mL is far beyond the typical range seen in stage II–III disease and warrants aggressive investigation. PET/CT should be strongly considered in this case to exclude occult distant disease, as it can change management in 8–11% of patients and is specifically recom...

I agree with the overall strategy of total neoadjuvant therapy here, particularly given the sphincter-abutting tumor and the goal of maximizing local control while addressing systemic risk.

That said, I tend to approach the sequencing a bit differently and not commit upfront to one fixed order.

With a...

Outside of a trial, the paradigm shift of radiation earlier in pMMR/MSS is increasing the proportion of patients who achieve a clinical complete or pathologic complete response.

Having said that, we underestimate how quickly systemic chemotherapy can help with symptoms of patients with rectal cancer....