In the United States, locally advanced rectal cancer has traditionally been treated with preoperative chemoradiotherapy (CRT) followed by Total Mesorectal Excision (TME) and adjuvant chemotherapy [1]. Despite excellent local control, rates of distant metastasis in this population can exceed 25 % [2–4]. Patients who achieve a clinical complete response (cCR) after neoadjuvant therapy may be safely observed via an organ preservation strategy instead of TME [5–13], which can be associated with sexual, urinary, bowel dysfunction, and/or permanent ostomy [14–16].