This study, a secondary analysis of the Organ Preservation in Patients with Rectal Adenocarcinoma (OPRA) trial, evaluates organ preservation (OP) and oncologic outcomes in patients with locally advanced rectal cancer treated with total neoadjuvant therapy (TNT). The OPRA trial introduced a 3-tier grading schema to categorize clinical tumor response (CCR, near complete response [NCR], and incomplete clinical response [ICR]). The analysis included 304 patients, with a median follow-up of 4.09 years. The 3-year probability of OP was significantly higher for patients with a CCR (77%) compared to those with an NCR (40%). Clinical tumor response grade was associated with disease-free survival, local recurrence-free survival, distant metastasis-free survival, and overall survival. The study suggests that the 3-tier grading schema can be used to predict OP and survival outcomes in patients with locally advanced rectal cancer after TNT.This study, a secondary analysis of the Organ Preservation in Patients with Rectal Adenocarcinoma (OPRA) trial, evaluates organ preservation (OP) and oncologic outcomes in patients with locally advanced rectal cancer treated with total neoadjuvant therapy (TNT). The OPRA trial introduced a 3-tier grading schema to categorize clinical tumor response (CCR, near complete response [NCR], and incomplete clinical response [ICR]). The analysis included 304 patients, with a median follow-up of 4.09 years. The 3-year probability of OP was significantly higher for patients with a CCR (77%) compared to those with an NCR (40%). Clinical tumor response grade was associated with disease-free survival, local recurrence-free survival, distant metastasis-free survival, and overall survival. The study suggests that the 3-tier grading schema can be used to predict OP and survival outcomes in patients with locally advanced rectal cancer after TNT.