This is the million dollar question. I think it comes down to patient preference. I think this person is eligible for both. PROSPECT requires that a patient will commit to surgery. TNT gives the option of non-operative management, but only for the ~30% of patients who have a cCR. I would get a high-quality rectal cancer-protocol MRI as EUS is suboptimal, especially for nodal staging. PROSPECT permitted either but that was due to lack of MRI at the time of the study. NCCN also notes that MRI is preferred: "Pelvic MRI with or without contrast. Endorectal ultrasound (if MRI is contraindicated, inconclusive, or for superficial lesions)." If this person is N2 by MRI, i would be inclined towards TNT. Otherwise, I think there is equipoise.