Intensity-modulated radiation therapy (IMRT) as neoadjuvant treatment of locally advanced rectal cancer (LARC) patients has been explored by some authors since 2006. Dosimetrical analyses and clinical outcomes have been published in recent years. Although there are encouraging dosimetrical results, there are no solid clinical data supporting the routine use of IMRT for preoperative treatment of LARC patients. In this article, we analyze the published dosimetrical and clinical data and current evidence for the use of IMRT in LARC patients. We hypothesize the role of IMRT to treat rectal cancer patients in the current technological age. The small bowel dose reduction that could lead to a reduction in GI toxicity and encourage higher rates of compliance, the potential dose escalation to the target volume, and the integration with higher doses of chemotherapy and its potential implications to optimize clinical outcomes in terms of toxicity and efficacy are discussed.