Clinical question list

Cite this page

Cancer Council Australia Colorectal Cancer Guidelines Working Party. Guidelines:Colorectal cancer/Clinical question list . In: Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Sydney: Cancer Council Australia. [Version URL: https://wiki.cancer.org.au/australiawiki/index.php?oldid=173128, cited 2023 May 28]. Available from: https://wiki.cancer.org.au/australia/Guidelines:Colorectal_cancer.

Last modified:
7 November 2017 23:45:43

This page lists the questions answered by systematic review and modelling. For full details about the reviews, including the inclusion and exclusion criteria, please see the Technical report.

Primary prevention (section lead: Finlay Macrae)

Clinical Question PPR1:
What is the risk-benefit ratio for use of aspirin for prevention of colorectal cancer stratified by risk of colorectal cancer itself? (What is the optimal dose and frequency of administration?)

PICO Question PPR1:
In an asymptomatic population at average risk or increased risk of colorectal cancer, what is the cost-benefit ratio of prophylactic Aspirin use in reducing the mortality and incidence of colorectal cancer?

Population	Intervention	Comparator	Outcomes	Study Design
Asymptomatic western population at average risk of colorectal cancer, or Populations at increased risk of colorectal cancer	Prophylactic aspirin use	Placebo or no Aspirin use	Colorectal cancer incidence Colorectal cancer mortality Adverse effects	Systematic reviews of Level II evidence or randomised controlled trials.

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Population screening for colorectal cancer (section leads: James St. John and Hooi Ee)

Clinical Question PSC1:
Is population screening based on testing with (a) immunochemical FOBT (iFOBT), (b) flexible sigmoidoscopy, (c) colonoscopy, (d) CT colonography, (e) faecal biomarkers such as DNA (f) plasma biomarkers such as DNA (g) any combination of the above screening tests effective in reducing bowel cancer mortality rates, feasible, acceptable and a cost-effective method of screening for the target population? a) Is population screening starting at an earlier age more effective, feasible, acceptable and cost-effective, compared with starting at age 50 years? b) In population screening, do the harms outweigh the benefits if routine screening by any method is continued beyond the age of 75 years?

PICO Question PSC1a (Screening benefit):
In persons without a colorectal cancer diagnosis or symptoms that might indicate colorectal cancer, which screening modality (immunochemical FOBT, flexible sigmoidoscopy, colonoscopy, CT colonography, faecal or blood biomarkers, or any combinations) compared with no screening, reduces colorectal cancer mortality, or the incidence of metastases at diagnosis?

Population	Intervention	Comparator	Outcomes
Persons without a colorectal cancer diagnosis or symptoms that might indicate colorectal cancer	Immunochemical FOBT, or Flexible sigmoidoscopy, or Colonoscopy, or Faecal biomarkers, or Blood biomarkers, or Any combinations.	No screening test	Colorectal cancer specific mortality Metastatic colorectal cancer diagnosis

PICO Question PSC1b (Screening test accuracy):
For persons without a colorectal cancer diagnosis or symptoms that might indicate colorectal cancer, which screening modality (immunochemical FOBT, flexible sigmoidoscopy, colonoscopy, faecal or blood biomarkers, or any combinations) performs best in detecting colorectal cancer, and how does the diagnostic performance change with family history, age, or gender?

Population	Index Test 1	Index Test 2	Reference standard	Outcomes
Persons without a colorectal cancer diagnosis or symptoms that might indicate colorectal cancer (with a family history of colorectal cancer or no family history of colorectal cancer)	Screening for CRC with: Immunochemical FOBT, or Flexible sigmoidoscopy, Colonoscopy, or Faecal biomarkers, or Blood biomarkers, or Any combinations	An alternative screening test or no screening	Colonoscopy or long-term follow up	Diagnostic performance related to advanced adenoma and colorectal cancer

PICO Question PSC1c (Screening cost effectiveness - modelling):
In persons without a colorectal cancer diagnosis or symptoms that might indicate colorectal cancer, what is the most cost-effective, feasible and acceptable screening modality (iFOBT, flexible sigmoidoscopy, colonoscopy, CT colonography, faecal or blood biomarkers test, or any combinations) compared with no screening?

PICO Question PSC1d (Screening age - modelling):
Is population screening starting at an earlier age more effective and as feasible, acceptable and cost-effective as screening starting at age 50 years? In population screening, do the harms outweigh the benefits if routine screening is continued beyond the age of 75 years?

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The symptomatic patient (section lead: Jon Emery)

Clinical Question SPT1-2:
What signs/symptoms alone or in combination are most predictive of CRC and what is the optimal maximum time from referral to diagnosis and treatment (diagnostic interval)?

PICO SPT1-2a (signs/symptoms):
In symptomatic patients without a colorectal cancer diagnosis, what signs or symptoms (persistent changed bowel movements, persistent diarrhoea or constipation, unexplained rectal bleeding, general or localised abdominal pain, unexplained palpable abdominal or rectal mass, unexplained weight loss, iron deficient anaemia, tiredness, fatigue, or any combination) correlate best with a diagnosis of colorectal cancer?

Population	Signs/Symptoms	Outcomes
Patients without colorectal cancer diagnosis presenting with symptoms of colorectal cancer	Signs or symptoms alone or in combination: persistent changed bowel movements persistent diarrhoea or constipation unexplained rectal bleeding general or localised abdominal pain unexplained palpable abdominal or rectal mass unexplained weight loss iron-deficient anaemia tiredness or fatigue rectal or anal pain	Diagnosis of colorectal cancer Specificity Sensitivity Positive predictive value Negative predictive value AUC of ROC

Clinical Question SPT1-2:
What signs/symptoms alone or in combination are most predictive of CRC and what is the optimal maximum time from referral to diagnosis and treatment (diagnostic interval)?

PICO Question SPT1-2b (diagnostic interval):
In symptomatic patients without a colorectal cancer diagnosis, what is the optimal maximum diagnostic interval that achieves better than or equivalent outcomes in terms of survival, mortality, and diagnosis of metastatic disease?

Population	Intervention	Comparator	Outcomes
Symptomatic patients without a colorectal cancer diagnosis	The time delay between presentation with symptoms associated with colorectal cancer and treatment for colorectal cancer	An alternative delay, or immediate treatment	3-year survival, or 5-year survival, or Colorectal cancer mortality Metastatic disease at diagnosis

Risk and screening based on family history (section lead: Mark Jenkins)

Clinical Question FHS2:
What is the strength of association between family history and colorectal cancer risk and how do these associations vary by, number of affected relatives and degree of relatedness and age and sex of affected relatives and by the age and sex of the at-risk person?

PICO Question FSH2:
For individuals, has a family history of colorectal cancer been shown to be reliably associated with an increase in risk of occurrence of or death from colorectal cancer when compared to individuals who do not have a family history of colorectal cancer?

Population	Exposure	Comparator/ Reference group	Outcomes
Persons without a colorectal cancer diagnosis or symptoms that might indicate colorectal cancer	Presence of a family history of colorectal cancer	No known family history of colorectal cancer	Colorectal cancer mortality Colorectal cancer diagnosis

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Pathology and staging (section leads: Charles Chan and Pierre Chapuis)

Clinical Question PTH1:
What is the optimal molecular profiling of colorectal cancer?

PICO Question PTH1:
In patients diagnosed with colorectal cancer who have undergone surgical resection or biopsy of the primary colorectal tumour, which molecular marker (BRAF/KRAS/NRAS/DNA mismatch repair /microsatellite instability) best predicts response to surgery, or adjuvant therapy or radiotherapy (disease-free survival, overall survival, disease-specific mortality, overall mortality, or relapse incidence)?

Population	Prognostic factor	Outcomes
Patients diagnosed with colorectal cancer and have had resection of the primary tumour (any age, with or without a family history of CRC, or any stage of CRC including M1)	Any single prognostic marker (or any combination) examined in the primary resected colorectal cancer tumour tissue: Immunohistochemical markers: BRAF Mismatch repair enzymes (MLH1, MSH2, PMS2, MSH6) PCR markers: BRAF Microsatellite instability (which loci?) KRAS NRAS	Response to surgery, or adjuvant therapy or radiotherapy, including: disease-free survival overall survival disease-specific mortality overall mortality relapse incidence

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Preparation for surgery and peri-operative optimisation (section lead: Elizabeth Murphy)

Clinical Question PRP2-5, 7:
Can peri operative management be optimised?

PICO Question PRP2-5, 7:
In patients diagnosed with colorectal cancer and undergoing surgical tumour resection, does mechanical bowel preparation with or without antibiotic prophylaxis, when compared to usual care, achieve better outcomes in terms of anastomotic leakage, surgical site infection, length of hospital stay and ileus?

Population	Intervention	Comparator	Outcomes
Patients diagnosed with colorectal cancer and undergoing surgical tumour resection of curative intent	Either: Mechanical bowel preparation with oral and intravenous antibiotic prophylaxis or Mechanical bowel preparation and intravenous antibiotic prophylaxis or Mechanical bowel preparation and oral antibiotic prophylaxis	No mechanical bowel preparation	Anastomotic leakage/dehiscence rates Rate of surgical site/wound infection Length of hospital stay Ileus

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Elective and emergency surgery for colon and rectal cancer

Clinical Question COL1-2a and b:
What is the optimal approach to resection of colorectal cancers?

PICO Question COL1-2a (section lead: Andrew Luck):
In patients diagnosed with colon cancer, what is the optimal resection strategy to achieve the best outcomes in terms of length and quality of life?

Population	Intervention	Comparator	Outcomes
Patients diagnosed with colon cancer and undergoing tumour resection	Laparoscopic colon resection	Open colon resection (colectomy)	Colorectal cancer mortality Perioperative morbidity Perioperative mortality Length of hospital stay Post-op time to return of bowel function Length of operation Quality of life Adverse events

PICO Question COL1-2b (section lead: Alexander (Sandy) Heriot):
In patients diagnosed with rectal cancer, what is the optimal resection strategy to achieve the best outcomes in terms of length and quality of life?

Population	Intervention	Comparator	Outcomes
Patients diagnosed with rectal cancer and undergoing tumour resection	Polypectomy Local transanal resection Transanal endoscopic microsurgery Total mesorectal excision Abdominoperineal resection Anterior resection Laparoscopic resection Open resection	An alternative resection strategy	Colorectal cancer mortality 30-day mortality rate Perioperative mortality 2-year survival 5-year survival Local recurrence rate Perioperative morbidity Permanent stoma rate Quality of life Adverse events

Clinical Question REC3:
What is the most effective treatment for early rectal cancer?

PICO Question REC3 (section lead: Alexander (Sandy) Heriot):
In patients diagnosed with stage I-II rectal cancer, what is the most effective treatment strategy to achieve the best outcomes in terms of length and quality of life?

Population	Intervention	Comparator	Outcomes
Patients diagnosed with localised stage I-II potential resectable rectal cancer (nodal status unknown)	Local resection with or without radiotherapy or chemotherapy	Radical resection with or without radiotherapy or chemotherapy	Overall survival 30-day survival Local recurrence (positive nodes or margins) Rectal cancer mortality Quality of life Adverse events Stoma rates

Clinical Question COLMNG5:
What are the benefits of stenting or colostomy vs. acute resection with primary anastomosis in acute obstruction due to left-sided colon or rectal carcinoma?

PICO Question COLMNG5 (section leads: Alexander (Sandy) Heriot and Andrew Luck):
In patients diagnosed with colorectal cancer and acute obstruction, does stenting or colostomy achieve equivalent or better outcomes compared to acute resection with primary anastomosis?

Population	Intervention	Comparator	Outcomes
Patients diagnosed with colorectal cancer and acute obstruction (due to left-side colon cancer or rectal cancer)	Stenting, or Colostomy, or Hartmann’s procedure	Acute surgical resection with primary anastomosis	Perioperative mortality Perioperative morbidity 5 year survival Cancer specific survival Length of hospital stay Stoma rate (temporary or permanent) Quality of life Adverse events

Clinical Question COLMNG3: (Section leads: Cherry Koh and Andrew Luck)
What is the role for peritonectomy with or without PIC in the treatment recurrent as well as primary colorectal cancer with peritoneal involvement (not including appendiceal neoplasia)?

PICO Question COLMNG3 (Section leads: Cherry Koh and Andrew Luck):
For patients diagnosed with colorectal cancer and peritoneal involvement or isolated peritoneal recurrence of colorectal cancer, does peritonectomy, with or without perioperative intraperitoneal chemotherapy (PIC), achieve better outcomes in terms of length and quality of life than usual care?

Population	Intervention	Comparator	Outcomes
Patients diagnosed with colorectal cancer and peritoneal involvement or isolated peritoneal recurrence of colorectal cancer	Peritonectomy with or without HIPEC	Usual care (systemic chemotherapy)	Colorectal cancer specific mortality 30-day mortality 5-year survival Quality of life Adverse events

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Adjuvant therapy for colon cancer (section lead: Peter Gibbs)

Clinical Question ADJ1:
What is the efficacy of adjuvant combination chemotherapy in elderly patients with colon cancer?

PICO Question ADJ1:
In elderly patients (≥70 years) diagnosed with colon cancer, what is the efficacy of surgery and adjuvant combination chemotherapy (involving either 5-flurouracil or capecitabine combined with oxaliplatin), compared to surgery with a single chemotherapeutic agent (fluoropyrimidine based) in achieving the best outcomes in terms of colorectal cancer mortality, recurrence, quality of life and adverse effects?

Population	Intervention	Comparator	Outcomes
Elderly patients diagnosed with colon cancer (≥70 years)	Surgery in combination with one of the following: Chemotherapy (either 5-Fluoruracil, Capecitabine, or Oxaliplatin) AND an additional adjuvant chemotherapy drug (either 5-fluoruracil, capecitabine, or oxaliplatin)	Surgery with a single chemotherapeutic agent (Fluoropyrimidine based).	Colorectal cancer mortality Colorectal recurrence Quality of life Adverse events

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Neo-adjuvant and adjuvant therapy for rectal cancer (section leads: Desmond Yip and Kathryn Field)

Clinical Question NEO1a-b:
Which patients with rectal cancer stage I-II could be considered for definitive chemoradiotherapy (no surgery), neo-adjuvant chemoradiotherapy or surgery alone?
a) What is the optimal timing for surgery after neoadjuvant therapy?
b) Should they be restaged?

PICO Question NEO1b:
For patients diagnosed with stage I-III rectal cancer, for which patients does neoadjuvant treatment (short or long course chemoradiotherapy) with surgery achieve equivalent or better outcomes in terms of length and quality of life than surgery alone?

Population	Intervention	Comparator	Outcomes
Patients diagnosed with stage I-III rectal cancer	Surgery without neoadjuvant therapy	Short/long course chemoradiotherapy with surgery	Rectal cancer mortality 30-day mortality Distant metastases Disease-free survival Overall survival Local recurrence Quality of life Sexual dysfunction Adverse events Rehospitalisation Permanent stoma formation Return to normal bowel function

PICO Question NEO1a:
For patients diagnosed with stage I-III rectal cancer, for which patients does neoadjuvant treatment (short or long course chemoradiotherapy) with surgery achieve equivalent or better outcomes in terms of length and quality of life than neoadjuvant chemoradiotherapy alone?

Population	Intervention	Comparator	Outcomes
Patients diagnosed with stage I-III rectal cancer	Definitive neoadjuvant chemoradiotherapy	Neoadjuvant chemoradiotherapy with surgery	Rectal cancer mortality 30-day mortality Distant metastases Disease-free survival Overall survival Local recurrence Quality of life Sexual dysfunction Adverse events Rehospitalisation Permanent stoma formation Return to normal bowel function

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Management of resectable locally recurrent disease and metastatic disease (section lead: Cherry Koh)

Clinical Question MNG13:
Which patients with locally recurrent colon or rectal cancer are more suitable for curative surgery?

PICO Question MNG13:
In patients with locally recurrent colon or rectal cancer, what is the role of curative surgery (+/- chemotherapy +/- radiotherapy) when compared to surgical palliation +/- palliative chemotherapy +/- palliative radiotherapy or other palliative interventions in terms of outcomes (overall survival, disease free survival, quality of life and complications)?

Population	Intervention	Comparator	Outcomes
Patients diagnosed with locally recurrent colon or rectal cancer	Curative surgery with or without chemotherapy, with or without radiotherapy	Surgical palliation with or without palliative chemotherapy or radiotherapy and/or palliative care	Overall survival Disease-free survival Quality of life Complications

Clinical Question MNG14:
Which patients with resectable synchronous or metachronous metastatic colon or rectal cancer are suitable for curative surgery?

PICO Question MNG14:
In patients with resectable synchronous or metachronous metastatic colorectal cancer, what is the role of surgical resection +/- chemotherapy when compared to non-surgical /palliative interventions in terms of outcomes (overall survival, disease free survival, progression free survival, quality of life and complications?)

Population	Intervention	Comparator	Outcomes
Patients diagnosed with metastatic colon or rectal cancer and synchronous or metachronous resectable metastases	Curative surgery With or without chemotherapy With or without radiotherapy	Non-surgical (chemotherapy, radiotherapy, etc) and/or palliative care	Overall survival Disease-free survival Quality of life Complications

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Management of non-resectable locally recurrent disease and metastatic disease (section lead: Louise Nott)

Clinical Question MNG16:
What is the impact of different liver directed therapies in patients with incurable metastatic colorectal cancer?

PICO Question MNG16:
In patients with incurable metastatic colorectal cancer, what are the effects of liver-directed therapies on survival and quality-of-life outcomes, compared with standard care?

Population	Intervention	Comparator	Outcomes
Patients with metastatic incurable colorectal cancer	Liver directed therapies involving: Trans-arterial (chemo) embolization, or Hepatic intra-arterial infusion, or Stereotactic radiotherapy, or Radiofrequency ablation Radioembolization in particular SIR-Spheres	Standard care (no therapy or, systemic chemotherapy with or without biologic surgery)	Colorectal cancer mortality, or Survival (progression free or overall), or Quality of life, or Adverse events, or Surgical resection rate

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Follow up after curative resection for colorectal cancer (section lead: Peter Lee)

Clinical Question FUR1-2:
What is the optimal intensity of follow up post curative resection of colorectal cancer? And where?

PICO Question FUR1-2a:
In patients who have had curative resection of colorectal cancer, what surveillance protocol achieves the best outcomes in terms of detected recurrent disease, 5-year survival, quality of life, and colorectal cancer-related mortality?

Population	Intervention	Comparator	Outcomes
Patient who have had curative resection of colorectal cancer	Follow-up including: Sigmoidoscopy, or Serum CEA test, or Imaging (CT scan), or Chest X-ray, or FOBT, or Ultrasonographic screening	An alternative follow-up modality	Colorectal cancer mortality, or Recurrence rates, or Rate of curative resection following recurrence, or Time to recurrence, or- 5 year survival, or Quality of life

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Referring to the large bowel, comprising the colon and rectum.

Measures to prevent the onset of disease. This may include prevention strategies to modify cancer risk factors, such as dietary and lifestyle interventions, and medical interventions to enhance resistance to the effects of exposure to a disease agent, such as chemoprevention and vaccines.

A common medication used to treat pain, fever, and inflammation. Also known as acetylsalicylic acid (ASA).

A test that can detect microscopic amounts of blood in stools. Types of FOBT include immunochemical FOBTs (iFOBTs), which directly detect haemoglobin using antibodies specific for the globin moiety of human haemoglobin, and guaiac FOBTs (gFOBTs), which detect peroxidase activity, an indirect method for identification of haemoglobin.

Also known as virtual colonoscopy, a medical imaging procedure that uses low dose radiation CT scanning to obtain an interior view of the colon (the large bowel) that is otherwise only seen with a more invasive procedure where an endoscope is inserted into the rectum and passed through the entire colon.

Performing tests to identify disease in people before any symptoms appear.

A procedure used by physicians to examine the inner lining of the rectum, particularly the lower portion of the colon (unlike the colonoscopy that examines the entirety of the colon). It consists of a flexible tube that is approximately 60 cm long, a small light and a camera attached at the tip of the tube.

An examination of the large bowel using a camera on a flexible tube, which is passed through the anus.

Cancer that has spread from the primary site of origin (where it started) into different area(s) of the body.

A measure for the likelihood (probability) that the subject with a positive screening result has the disease being tested for.

A medical specialty that determines the cause and nature of diseases by examining and testing body tissues, for instance from laboratory examination of samples of body tissue.

The removal of polyps from the bowel.

The local resection of tumour through the anus.

A procedure used in the treatment of colorectal cancer in which a significant length of the bowel around the tumour is removed.

An operation for rectal cancer. This involves removing part of the colon, and the rectum and anus, and creating a permanent colostomy.

A surgical procedure to remove cancer in the rectum with the bowel being re-joined to leave a functioning anus.

The reappearance of cancer at a site that was previously treated and responded to therapy.

A surgical procedure to remove the cancerous part of the lining of the abdominal cavity.

A treatment given with or shortly after another treatment to make it more effective. This usually refers to surgery followed by chemotherapy or radiotherapy.

Carcinoembryonic antigen. A protein that may be found in the blood of a person with colorectal cancer.

Using scans, including nuclear medicine, to create images of the interior of a body for clinical analysis and medical intervention.

A computerised tomography (CT) scan, which x-ray equipment to create detailed digital images, or scans, of areas inside the body.