Malignancy

Diagnosis and management of colorectal cancer:summary of NICE guidance

© BMJ Publishing Group Ltd 9 November 2011
د. حسين محمد جمعة
اختصاصي الامراض الباطنة
البورد العربي
كلية طب الموصل
2011

Colorectal cancer is the third leading cause of death from cancer in the United Kingdom, with a lifetime risk of about 2% in England and Wales, and its incidence is rising. The outcome for people with colorectal cancer is improving, but the overall five year survival rates are still lower than 60%. There is a need for greater accuracy in diagnosis and staging, more appropriate use of neoadjuvant and adjuvant therapies when treating potentially curable disease, and more effective use of resources when managing patients with advanced disease.

Recommendations

NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available,recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice.

Investigations for diagnosis and staging

Confirming a diagnosis of colorectal cancer
• Advise the patient that more than one investigation may be necessary to confirm or exclude a diagnosis of colorectal cancer.
• Offer colonoscopy to patients without major comorbidity.
If a lesion suspicious of cancer is detected, perform abiopsy unless contraindicated (for example, in patients with bleeding disorders).


For patients with major comorbidity, offer flexible
sigmoidoscopy followed by a barium enema. If a lesion
suspicious of cancer is detected perform a biopsy unless contraindicated.
Consider computed tomographic colonography as an alternative to colonoscopy or to flexible sigmoidoscopy with a barium enema, if the local radiology service can show competency in this technique. If a lesion suspicious of cancer is detected, offer colonoscopy with biopsy to confirm the diagnosis, unless it is contraindicated.

Offer patients who have had an incomplete colonoscopy:-Repeat colonoscopy or -Computed tomographic colonography, if the local radiology service can show competency in this technique
Or barium enema.

Staging

For all patients diagnosed with colorectal cancer offer contrast enhanced CT scanning
of the chest, abdomen, and pelvis to estimate disease stage, unless it is contraindicated.
For all patients with rectal cancer offer MRI to assess the risk of local recurrence
(as determined by anticipated resection margin and staging of the tumour and lymph nodes) unless it is contraindicated.If MRI shows disease amenable to local excision or if MRI is contraindicated, offer endorectal ultrasonography.
Do not use the findings of a digital rectal examination as part of the staging assessment.

Information about bowel function

Offer all patients information on all treatment options
available to them (including no treatment) and the potential benefits and risks of these treatments, including the effect on bowel function.
Before surgery offer all patients information about the
likelihood of having a stoma, why it might be necessary,
and how long it might be needed for.
Ensure that a trained stoma professional gives specific
information on the care and management of stomas to all
patients considering surgery that might result in a stoma.


Management of local disease
Patients whose primary rectal tumour appears resectable at presentation
Do not offer short course preoperative radiotherapy or chemoradiotherapy to patients with operable rectal cancer at low risk of local recurrence, unless as part of a clinical trial.
For patients with operable rectal cancer at moderate risk of local recurrence consider short course preoperative radiotherapy then immediate surgery.

For patients whose tumours fall between moderate and high risk of local recurrence, consider preoperative chemoradiotherapy then surgery, but with an interval before surgery to allow the tumour to respond and shrink.
For patients with operable rectal cancer at high risk of local recurrence offer preoperative chemoradiotherapy then surgery, but with an interval before surgery to allow the tumour to respond and shrink (rather than short course preoperative radiotherapy)

Patients whose primary tumour appears unresectable or borderline resectable

For patients with locally advanced rectal cancer at high
risk of local recurrence, offer preoperative chemoradiotherapy then surgery, but with an interval before surgery to allow the tumour to respond and shrink.
Do not offer preoperative chemoradiotherapy solely to
facilitate sphincter sparing surgery.
Do not routinely offer preoperative chemotherapy alone
for patients with locally advanced colon or rectal cancer
unless as part of a clinical trial.

Colonic stents in acute large bowel obstruction

If stenting is being considered for patients presenting with acute large bowel obstruction, offer CT scanning of the chest, abdomen, and pelvis to confirm the diagnosis of mechanical obstruction and to determine whether the patient has metastatic disease or colonic perforation.
Do not use contrast enema studies as the only imaging modality.


The decision to insert a stent should be made by aconsultant colorectal surgeon with an endoscopist or aradiologist, or both. Only healthcare professionals experienced in placing colonic stents and with access to fluoroscopic equipment and trained support staff should
insert colonic stents.

Consider placing a self expanding metallic stent to initially manage left sided complete or near complete colonic obstruction; do not dilate the tumour beforehand.
Do not place self expanding metallic stents:
-In low rectal lesions or -To relieve right sided colonic obstruction or -If there is clinical or radiological evidence of colonic perforation or peritonitis.
If a self expanding metallic stent is suitable try insertion urgently and no longer than 24 hours after patients present with colonic obstruction.

For patients with locally excised, pathologically confirmed stage I colon cancer:

The colorectal multidisciplinary team should consider
offering further treatment, taking into account pathological characteristics of the lesion, imaging results, and previous treatments.
Offer further treatment to patients whose tumour had
involved resection margins of less than 1 mm.
For patients with stage I rectal cancer amultidisciplinary
team specialising in early rectal cancer should decide
which treatment to offer, taking into account previous
treatments, such as radiotherapy.
Stage I colorectal cancer

Laparoscopic surgery

The recommendations on laparoscopic surgery for colorectal cancer are covered by NICE’s technology appraisal


Staging of colorectal cancer
Stage I—Primary tumour into but not through muscularis propria, and no metastases
Stage II—Primary tumour grown through to serosa and peritoneal surface but no metastases
Stage III—Any size of primary tumour with lymph node metastases
Stage IV—Presence of distant metastatic disease

Adjuvant chemotherapy

After fully discussing the risks and benefits with the patient,consider adjuvant chemotherapy for patients with stage II rectal cancer with high risk of recurrence and all patients with stage
III rectal cancer, and for patients with stage II colon cancer with high risk of recurrence and all patients with stage III colon cancer.

Management of metastatic disease

Stage IV colorectal cancer
Prioritise treatment to control symptoms if at any point the patient has symptoms from the primary tumour.
If both primary and metastatic tumours are considered resectable, site specific multidisciplinary teams (teams specialising in all relevant anatomical sites of the cancer) should consider initial systemic treatment followed by surgery, after full discussion with the patient.

Offer contrast enhanced CT scanning of the chest,

abdomen, and pelvis to patients being assessed for
metastatic colorectal cancer.
Discuss all imaging with the patient after review by the appropriate site specific multidisciplinary team.
If the CT scan shows metastatic disease only in the liver and there are no contraindications to further treatment, aspecialist hepatobiliary multidisciplinary team should decide if further imaging is needed to confirm whether surgery is suitable or potentially suitable after further treatment.


Chemotherapy and biological therapies
Full details on the use of these therapies can be found in NICE guidance.
In patients with advanced colorectal cancer:
Consider one of the following sequences of chemotherapy:
-FOLFOX (folinic acid plus fluorouracil plus oxaliplatin)
as first line treatment then single agent irinotecan as second line treatment or -FOLFOX as first line treatment then FOLFIRI (folinic acid plus fluorouracil plus irinotecan) as second line treatment or
-XELOX (capecitabine plus oxaliplatin) as first line
treatment then FOLFIRI as second line treatment.

Consider raltitrexed only for patients with advanced

colorectal cancer who are intolerant to fluorouracil and
folinic acid or for whom these drugs are not suitable.
Note that at the time of publication (November 2011), irinotecan did not have UK marketing authorisation for use in second line combination therapy (FOLFIRI (folinic acid plus fluorouracil plus irinotecan)). Informed consent should be obtained and documented.

Ongoing care and support

Follow-up after apparently curative resection
Offer follow-up to all patients—to start at a clinic visit four to six weeks after potentially curative treatment.
Offer regular surveillance with:
-At least two CT scans of the chest, abdomen, and pelvis in the first three years and -Regular serum carcinoembryonic antigen tests (at least every six months in the first three years).

Offer a surveillance colonoscopy at one year after initial

treatment. If this is normal consider further colonoscopy after five years, and thereafter as determined by cancer networks. Determine the timing of surveillance for patients with subsequent adenomas by the risk status of the
adenoma.


Start investigations again if there is any clinical,
radiological, or biochemical suspicion of recurrent disease.
Stop regular follow-up when:
-The patient and the healthcare professional have discussed and agreed that the likely benefits no longer outweigh the risks of further tests or
-The patient cannot tolerate further treatments.

After any treatment, offer all patients specific information on managing the effects of the treatment on their bowel function. This could include information on incontinence, diarrhoea, difficulty emptying their bowels, bloating, excess flatus, diet, and where to go for help in the event of symptoms.
Offer verbal and written information in a way that is clearly
understood by patients and free of jargon. Include
information about support organisations or internet
resources recommended by the clinical team.

Overcoming barriers

The guideline deals with many major uncertainties in the diagnosis and treatment of colorectal cancer, including the uncertainty about which patients to refer for consideration of resection of colorectal cancer liver metastases (currently the best performing hospital refers 10 times as many patients as the worst performing hospital).

The guidance on referral for all patients with liver limited disease who are fit for further surgery
(that they should be referred to specialist liver surgery multidisciplinary teams for decisions on further definitive imaging) will substantially increase the chance of such patients being offered potentially curative surgery. Successful treatment of colorectal cancer depends highly on good multiprofessional and multidisciplinary working, requiring effective communication among the different healthcare teams.

Future research and remaining uncertainties

The effectiveness of preoperative chemotherapy alone should be compared with short course preoperative radiotherapy,chemoradiotherapy, or surgery alone in patients with locally advanced rectal cancer with moderate risk of recurrence. Outcomes of interest are local control, toxicity, overall survival, quality of life, and cost effectiveness
An observational study should be conducted to assess the value of the proposed prognostic factors in guiding the optimal subsequent management. Outcomes of interest are disease-free survival, overall survival, local and regional control, toxicity, cost effectiveness,and quality of life


A prospective trial should be conducted to investigate the most clinically and cost effective sequence in which to perform MRI and
PET-CT to determine resectability after an initial CT scan in patients with colorectal cancer that has metastasised to the liver. The outcomes of interest are reduction in futile laparotomies and improvement in overall survival

Strategies to integrate oncological surveillance with optimising quality of life, reducing late effects, and preventing second cancers in
survivors of colorectal cancer should be developed and explored
Patient reported outcome measures specific to colorectal cancer should be developed for use in patient management and to inform
outcome measures in future clinical trials
© BMJ Publishing Group Ltd 9 November 2011