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The treatment outcomes of locally advanced rectal cancer (LARC) have significantly improved in the last few decades due to the continuous evolution of multimodality management. However, the distant failure remains a concern leading to more cancer-related deaths. Conventionally, preoperative chemoradiotherapy followed by total mesolectal excision and adjuvant chemotherapy is the standard of care for LARC patients. However, noncompliance to adjuvant chemotherapy due to various factors leads to more distant failure rates. As an alternative to this, multiple approaches of total neoadjuvant therapy (TNT) were investigated over time, and multiple reports have shown promising results. This review highlights the evolution of the multimodality management approach to LARC patients, emphasising preoperative radiotherapy and TNT.