Management of patients with newly diagnosed with metastatic colorectal cancer (mCRC) may be complex, and treatment decisions benefit from multidisciplinary input. The optimal treatment strategy for patients with non-resectable metastatic colorectal cancer is rapidly evolving. Management must be individualised based on the overall medical condition of the patient, the extent and distribution of metastatic disease and the patient’s wishes. Among patients with mCRC, curative treatment can only be proposed for those in whom both the primary and distant metastases are resectable either initially or following “conversion” therapy. It is important to identify this group of patients as they have the greatest likelihood of cure. Unfortunately, only a minority of patients are suitable for curative resection; approximately 20% of mCRC patients. The majority of patients will not have disease that can be surgically resected with curative intent. For these patients, the goal of care is generally palliative. Aims may include prolongation of survival, improvement of tumour related symptoms, and maintenance of quality of life.
For an individual patient, defining the goal of treatment informs the choice of first-line systemic treatment and the integration and sequencing of multimodal therapies. Palliative chemotherapy and other systemic therapies can significantly improve overall survival and quality of life, and are the mainstay of therapy for patients with non-resectable metastatic colorectal cancer who have adequate performance status to undergo these treatments. For select patients with liver limited non-resectable disease, loco-regional liver-directed therapies may be considered. In this situation with goal of therapy is not necessarily cure but may allow discontinuation of standard systemic therapy, with the possibility of a (meaningful) relapse/disease free-interval. There are a number of evolving liver directed therapies to consider including (but not limited to) invasive local ablation (RFA), embolization techniques (particle, bead, Selective internal radiation therapy (SIRT)) and precision radiotherapy (Stereotactic body radiotherapy (SBRT)).
Another important group of mCRC (up to 25% of mCRC patients) are those who at the time of diagnosis of their primary colorectal cancer have synchronous metastases. Initial management of the primary site in patients who present with metastatic disease is controversial and not fully addressed by currently available literature. In general, the choice and sequence of treatment is guided by the presence and absence of symptoms from the primary tumour and whether or not the metastases are potentially resectable. Such decisions are usually made by a multidisciplinary team (MDT) with expertise in the management of mCRC.
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