Putting radiation first.

The total neoadjuvant therapy (TNT) approach to locally-advanced rectal cancer has rapidly gained favor over the past couple of years, but here’s a novel question: what should come first, the radiation or the dedicated chemo? Here is a German phase 2 trial that randomized 306 evaluable patients to one or the other TNT sequence prior to surgery, and the winner was chemoradiation first then chemo. The primary endpoint of complete pathologic response rate was significantly higher with chemoradiation first (25%) versus with chemo first (17%). At the same time, there was no difference in disease-free, chronic toxicity, quality of life, or stool incontinence. | Fokas, JAMA Oncol 2021