Total Neoadjuvant Therapy and the Dimpled Doctor Who’ll Nuke My Butt

I met my radiation oncologist on Friday. His name is Dr. Calvin McAllister, which sounds like he should be moonlighting as a Southern senator or bottling bourbon. But no, he's at the Teton Cancer Institute—just radiation oncology, nothing extra, no sides, no frills. Just the ass-zapping essentials. And speaking of essentials, let’s talk about those dimples. And the fact that he’s bald now. I mean, we might be bald together soon. Bald is bonding. Bald is biblical. Bald is a shared fate wrapped in a lead apron and a faint scent of hand sanitizer.

When you walk into the Radiation Oncology Building at 1550 Hoopes, you’re greeted by the kind of sunlight that makes you question if this might be a trick. The light through the windows doesn’t feel clinical—it feels intentional. It rests gently on the floor like it’s comforting the laminate. It’s warm. Unflinchingly soft. As if God whispered to the architect, "Make grief glow." And they did. It’s hard to be cynical when the sun's giving you a shoulder rub.

The waiting room itself is oddly cozy, like someone’s Midwestern aunt tried to make you forget you were about to have your insides microwaved. There’s a fireplace. Faux stone, but I respect the effort. Chairs lined up like a slightly confused AA meeting. A bouquet of faux flowers taped to the TV, like the Easter Bunny moonlights as a radiation tech.

I sat there, not quite prepared to discuss how a locally advanced rectal tumor roughly the size of a dollar bill was about to be targeted with enough precision to make NASA jealous. I had recorded everything because frankly, how do you retain sentences like “We’ll need to virtually reconstruct your entire lower half so we can nuke your butthole with mathematical elegance”?

Dr. McAllister enters the room. Kind eyes. Casual attire. And there it is—a dimple. That kind of dimple that makes you think, yeah, this person could tell me my reproductive organs are collateral damage and I’d still want to bake him banana bread.

We get right to it. Total Neoadjuvant Therapy, or TNT—not to be confused with the network that reruns Bones. This is cancer treatment, not crime drama. TNT for rectal cancer is the new protocol: chemo, radiation, more chemo, possibly surgery, and a lot of me lying on cold tables while machines whirl with deadpan indifference.

TNT is relatively new on the rectal cancer scene—standardized in the U.S. only within the last few years. It flips the traditional order of treatment. Instead of surgery first and then chemo and radiation, TNT gives patients all the systemic treatment upfront—chemotherapy, radiation, then more chemotherapy—before surgery is even considered. The goal? Shrink the tumor, zap the surrounding lymph nodes, and if you’re lucky, obliterate every cancer cell in sight. In some cases, like mine, it might mean avoiding surgery altogether. It’s aggressive. It’s exhausting. But it gives you the best shot at walking away with everything intact—well, almost everything. (RIP, fertility.)

The tumor is nestled in my rectum, affecting at least three lymph nodes—maybe more. It’s not an out-of-town guest anymore. It’s unpacked, using my cervix as a hammock. We’ll be starting with a continuous infusion of 5FU chemo—Monday through Friday. Five days a week, like a demonic office job.

“I always remember it as five fuck you” Dr. McAllister quips.

First step: a CAT scan to plan radiation. That scan gets fed into software that basically makes a digital me. A virtual Rachel. I imagine her with better posture. Once she’s rendered, they design a plan to attack my tumor with precision. It’ll take them 2 to 4 days to sort out the physics and write the war strategy.

Then comes the verification visit, where I lie back on a table, and they simulate the real thing to ensure the radiation beams will hit the exact coordinates without friendly fire. It’s all very sci-fi but with worse gowns.

When I asked how long these daily treatments would last, he said, "About 30 minutes total, but the machine is only on for 4-5 of those minutes." So the rest of the time is just... foreplay.

He tells me I won’t be radioactive, and I can be around people. But I can’t get pregnant. Not because I’m suddenly celibate, but because if I did get pregnant, the radiation would essentially nuke any chance of viable eggs. My ovaries, uterus, cervix—they’re all in the line of fire. It’s a sobering moment. Like someone handing you a form that just says, "Motherhood, probably not." He recommends I meet with a fertility doctor first before we begin treatment. Again something not covered by my insurance.

What no one prepares you for is how permanent it feels when a stranger with a clipboard starts talking about your womb like it’s a parking space already zoned for demolition. You sit there nodding politely while they discuss your future like it’s already gone—like it wasn’t something you ever really had a right to. As if wanting children was always a luxury, not a birthright. And just like that, a door closes. Quietly. Without a bang. Like it was never open in the first place.

There’s a pain in hearing that your body will be scorched from the inside out and not even have the decency to leave behind a scar you can point to and say, “That’s where the dream burned down.” No. The damage will be internal. Invisible. Sterile.

We didn’t dwell, but it stuck to my ribs like dry toast. It’s one thing to know your body is changing. It’s another to feel your future shrink-wrap around that change.

Let’s talk side effects. Fatigue. Not the kind where you need a nap. The kind where you become furniture. Flat-on-your-back, can’t-move fatigue. Skin: Red, sore, like a sunburn in the world’s most inconvenient location. Picture a sunburn inside your butt crack. Nausea. Diarrhea. The usual suspects. Frequent urination and bladder issues. The whole pelvic neighborhood gets hit with some collateral damage.

Long-term? Chronic diarrhea. And by chronic, he means the kind where you stop planning road trips. The kind that makes you calculate the distance between bathrooms before you leave the house.

But the best-case scenario—the dream—is that chemo and radiation work so well, I won’t need surgery at all. That’s the tiny golden kernel I clutch in the middle of all the chaos.

I’m doing TNT to give myself the best shot at that. It’s a grueling protocol, but it has a shot at obliterating everything without a scalpel.

But first: I meet with a fertility doctor! More on that to come.

A blog post by Rachel Smak on grief, loss, and lessons from stage 3C rectal cancer