Summary of recommendations
This is a summary of the recommendations in these guidelines, numbered according to chapter to which they relate. Please note that some chapters do not have associated recommendations.
This guideline includes evidence-based recommendations (EBR), consensus-based recommendations (CBR) and practice points (PP) as defined in the table below. Recommendations and practice points were developed by working party members and sub-committee members.
Each EBR was assigned a grade by the expert working group, taking into account the volume, consistency, generalisability, applicability and clinical impact of the body of evidence according to NHMRC Level and Grades for Recommendations for Guidelines Developers.[1]
NHMRC approved recommendation types and definitions[edit source]
Definition | |
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A recommendation formulated after a systematic review of the evidence, indicating supporting references | |
A recommendation formulated in the absence of quality evidence, after a systematic review of the evidence was conducted and failed to identify admissible evidence on the clinical question | |
A recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process |
Source: National Health and Medical Research Council. Procedures and requirements for meeting the NHMRC standard for clinical practice guidelines. Melbourne: National Health and Medical Research Council, 2011
Evidence-based recommendation grades[edit source]
Description | |
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Body of evidence can be trusted to guide practice | |
Body of evidence can be trusted to guide practice in most situations | |
Body of evidence provides some support for recommendation(s) but care should be taken in its application | |
Body of evidence is weak and recommendation must be applied with caution |
Source: National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC; 2009. (https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf)
Recommendations
Primary prevention
Dietary and lifestyle strategies
Practice point![]() |
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Folic acid intake outside pregnancy should not exceed 1mg per day and those with a history of colorectal adenomas should not take more than 200mcg as a supplement. |
Practice point![]() |
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It is recommended to follow the primary prevention messages from the World Cancer Research Fund/American Institute for Cancer Research on tobacco smoking, alcohol, diet, body fatness, physical activity (see Table 2.3). |
Chemopreventive candidate agents
Practice point![]() |
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Aspirin should be avoided in patients with uncontrolled hypertension. |
Practice point![]() |
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Where surgery is inappropriate for people with familial adenomatous polyposis, an NSAID (e.g. sulindac) is recommended. (Kim B et al 2011) |
Practice point![]() |
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Without RCT evidence, statins cannot be recommended for chemoprevention at this time. |
Practice point![]() |
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Without RCT evidence, metformin cannot be recommended for chemoprevention at this time. |
Practice point![]() |
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Bisphosphonates cannot be recommended for chemoprevention. |
Population screening for colorectal cancer
Population screening: Evidence summary and recommendations (PSC1a-d)
Evidence-based recommendation![]() |
Grade |
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The use of flexible sigmoidoscopy as a primary screening test is not recommended for population screening in the average-risk population. |
Primary screening test
C |
Evidence-based recommendation![]() |
Grade |
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It is recommended that the age range for organised population screening continues to be 50–74 years. |
Target age group
N/A |
Evidence-based recommendation![]() |
Grade |
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Starting at age 40 is not recommended for population screening as it is unlikely to be cost-effective. |
Target age group
N/A |
Evidence-based recommendation![]() |
Grade |
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Extending the age range to 79 or 84 years is not recommended for population screening as it is unlikely to be cost-effective. |
Target age group
N/A |
Practice point![]() |
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Participation in a population screening program is not recommended for people with symptoms such as rectal bleeding or persistent change in bowel habit or with iron-deficiency anaemia, nor for those who should be having regular surveillance or screening based on colonoscopy, e.g. for past colorectal cancer or adenoma, chronic inflammatory bowel disease, a strong family history of colorectal cancer, or a high-risk genetic cancer syndrome (see Risk and screening based on family history of colorectal cancer). |
Practice point![]() |
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Individuals who have had a high-quality colonoscopy performed within the previous two years should allow another two years to elapse (i.e. skip a round) before participating in their next round of iFOBT screening. Colorectal cancer will rarely be present within that interval. High-quality colonoscopy is defined in the Clinical Practice Guidelines for Surveillance Colonoscopy. |
The symptomatic patient
Signs and symptoms predictive of colorectal cancer
Optimal maximum time from referral to diagnosis and treatment
Evidence-based recommendation![]() |
Grade |
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triage Categories 1 and 2, whether it is for a patient with symptoms or after a positive iFOBT used for colorectal cancer screening. Diagnostic intervals greater than 120 days are associated with poorer clinical outcomes.
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A diagnostic interval of 120 days should be the maximum time from first healthcare presentation† to diagnostic colonoscopy for D |
Risk and screening based on family history
Colorectal cancer risk according to family history
Practice point![]() |
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Approximately 95-98% of the population are in Category 1 (near average risk of developing colorectal cancer). |
Practice point![]() |
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Approximately 65% of those with a family history of colorectal cancer only have a weak family history which means they are category 1 risk. |
Practice point![]() |
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Medical information that patients provide about their relatives is often inaccurate. (St John et al 1993, Love et al 1985, Douglas et al 1999, Ruo et al 2001, Mitchell et al 2004) The percentage of colorectal cancer reports that are correct (positive predictive value) is 86% meaning that reports by relatives are usually true. However, a high proportion of people appear to be unaware that their relatives have had colorectal cancer, with the percentage of all colorectal cancers in first-degree relatives that are reported (sensitivity) being 27%. (Mai 2011). |
Practice point![]() |
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Given the potential importance of an accurate risk prediction for an individual, every effort should be made to collect reliable information. |
Screening strategies for people with a family history of colorectal cancer
Practice point![]() |
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For people with category 2 risk of colorectal cancer:
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Practice point![]() |
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For people in category 2, CT colonography can be offered if colonoscopy is contraindicated (Dachman 2003). |
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Category 2 can now be met by inclusion of relatives from both sides of the family. Genetic testing is not appropriate at present for people with category 2 risk. Tumour testing for Lynch syndrome-related changes, using immunohistochemistry and microsatellite instability, should be considered when any of the revised Bethesda criteria are met (see Lynch syndrome). |
Practice point![]() |
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For people with category 3 risk of colorectal cancer:
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Evidence-based recommendation![]() |
Grade |
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For people with a family history of colorectal cancer who are assessed as having category 1 risk, iFOBT should be performed every 2 years from age 50 to age 74. See Population screening for colorectal cancer. For those with one first-degree relative with colorectal cancer, iFOBT every two years from age 45 should be considered. |
Category 1
C |
High-risk familial syndromes
Familial adenomatous polyposis (FAP)
Practice point![]() |
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Surveillance should commence from age 10 to 15 years or earlier if there are gastrointestinal symptoms (Robays and Poppe, 2014). In families with classical FAP, flexible sigmoidoscopy is adequate since adenomas occur simultaneously throughout the colorectum (Syngal et al., 2015; Stoffel et al., 2015; Robays and Poppe, 2014). Once an adenoma is identified, annual colonoscopy should be performed until colectomy is undertaken. In AFAP, surveillance should be by colonoscopy since the first adenomas may only be present in the proximal colon but surveillance can be delayed until 18 years of age (Syngal et al., 2015; Cancer Institute NSW 2016; Robays and Poppe, 2014). |
Practice point![]() |
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MUTYH-associated polyposis
Practice point![]() |
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Testing may also be considered in patients with ≥ 10 adenomas and any of the following (Syngal et al., 2015) :
Clinical practice in some familial cancer clinics would accept patients in these categories even if there are no synchronous adenomas in the proband. |
Practice point![]() |
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Biallelic mutation carriers should have colonoscopy every 2 years starting at age 18 to 20 years(Cancer Institute NSW, 2016; Robays and Poppe, 2014; Balmaña et al., 2013). If polyps are detected, annual colonoscopy may be required to control the polyp burden (Cancer Institute NSW, 2016). If polyps cannot be easily managed colonoscopically, a colectomy with ileorectal anastomosis should be considered and discussed with the patient (Cancer Institute NSW, 2016; Balmaña et al., 2013) The residual rectum requires annual surveillance. |
Lynch syndrome
Practice point![]() |
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Juvenile polyposis syndrome
Practice point![]() |
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In patients with a diagnosis of juvenile polyposis syndrome, colonoscopy should commence at age 12–15 or earlier if symptoms occur (Syngal et al., 2015; Cancer Institute NSW, 2016). It should be repeated every 1 to 3 years depending on polyp burden. Colectomy is indicated if polyps cannot be managed endoscopically (Syngal et al., 2015; Cancer Institute NSW, 2016). |
Serrated polyposis syndrome
Practice point![]() |
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Expert opinion is that colonoscopy should be performed every 1 to 3 years with the aim to remove all polyps ≥ 5mm. If the number and size of polyps make it impossible to achieve this, colectomy and ileorectal anastomosis should be considered.(Syngal S, Brand RE, Church JM, Giardiello FM, Hampel HL, Burt RW, et al 2015)(Cancer Institute NSW 2016) |
Imaging a patient with a diagnosis of colon/rectal adenocarcinoma
Imaging for colon cancer
Practice point![]() |
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CT colonoscopy should be considered for a patient with colon cancer if it has not been possible to view the entire colon by colonoscopy due to the risk of synchronous tumours. (New Zealand Guidelines Group 2011.) |
Practice point![]() |
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For patients with colorectal cancer who have potentially resectable metastatic disease, PET-CT is recommended to detect additional metastases. |
Imaging for rectal cancer
Practice point![]() |
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MRI of the rectum is the recommended staging investigation for rectal cancer. |
Practice point![]() |
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High-resolution sequences must be performed and must meet accepted criteria. |
Practice point![]() |
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Additional sequences coronal to the anal canal are required for low tumours (Table 7.2). |
Pathlogy and staging
Selection of a clinicopathological staging system
Practice point![]() |
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TNM staging, ACPS/Concord staging and the data required to stage the patient should all be recorded to allow national and international comparisons. |
Additional information on pathology reporting
Practice point![]() |
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DNA mismatch repair status studies should be performed on all cases of colorectal cancer for the detection of Lynch syndrome. |
Optimal molecular profiling
Practice point![]() |
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A suitable tissue block with a high proportion of tumour tissue (preferably over 70%) should be designated for the purpose of further molecular testing if required. |
Preparation for surgery and peri-operative optimisation
Multidisciplinary meetings
Practice point![]() |
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Ideally, all patients with newly diagnosed colorectal cancer should be discussed at a multidisciplinary team meeting. |
Practice point![]() |
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Discussion at a multidisciplinary team meeting is mandatory for high-risk and complex cases such as patients with preoperative rectal cancers, metastatic disease or recurrent disease. |
Perioperative anaemia management
Practice point![]() |
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Patients undergoing elective surgery for colorectal cancer should be assessed for anaemia and iron deficiency and any deficiencies should be addressed preoperatively. |
Practice point![]() |
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Intravenous iron should be considered in preference to oral iron preoperatively given its quicker therapeutic effect. |
Practice point![]() |
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Consideration should also be given to treating postoperative functional iron deficiency anaemia with intravenous iron. |
Thromboembolic prophylaxis
Nutritional interventions
Practice point![]() |
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Patients undergoing elective surgery for colorectal cancer should be screened for malnutrition. |
Practice point![]() |
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If patients are found to be malnourished, nutritional interventions should be put in place. |
Stomal therapy
Practice point![]() |
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Patients undergoing colorectal cancer surgery who may, or will, require a stoma should be seen prior to surgery by a stomal therapist. |
Practice point![]() |
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Patients with stomas should be given postoperative education. |
Body temperature
Practice point![]() |
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Perioperative normothermia should ideally be maintained at or above 36.0˚C. |
Practice point![]() |
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The use of warmed IV fluids and forced-air warming can be used to minimise perioperative hypothermia. |
Enhanced recovery after surgery
Practice point![]() |
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Patients having elective surgery for colorectal cancer should be managed within an appropriately resourced enhanced recovery after surgery (ERAS) program. |
Mechanical bowel preparation with or without antibiotic prophylaxis
Elective and emergency surgery for colon and rectal cancer
Optimal approach to elective resection for colon cancers (COL1-2a)
Evidence-based recommendation![]() |
Grade |
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Either an open approach or a laparoscopic approach can be used for the resection of colon cancer. | D |
Optimal approach to elective resection for rectal cancers (COL1-2b)
Practice point![]() |
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Regardless of the approach utilised, rectal cancer resection must be undertaken by surgeons who have been appropriately trained in surgical resection of rectal cancer, utilising the principles of total mesorectal resection as proposed by Heald. This should include sharp dissection undertaken along the mesorectal plane. Surgical resection undertaken by inadequately trained surgeons is likely to result in inferior oncological outcomes. |
Practice point![]() |
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The laparoscopic approach may have a higher potential for an inferior quality TME specimen, as demonstrated by two recent multicentre RCTs, though long-term outcome data are not yet available on these studies (Fleshman et al 2015, Stevenson et al 2015). Two other large multicentre RCTs have reported long-term outcomes with no difference in local recurrence or survival (Jeong et al 2014, Bonjer et al 2015). The surgeon should discuss with the patient the potential impact on oncological outcome of the laparoscopic approach along with the potential improvements on short term recovery. |
Local versus radical resection for T1-T2 rectal tumours (REC3)
Evidence-based recommendation![]() |
Grade |
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For patients with T2 tumours, consider radical resection as the first option if they are fit for surgery. | C |
Practice point![]() |
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Radical resection is recommended for patients with T1sm3 tumours, and for those with T2 tumours who are considered fit for radical surgery. |
Practice point![]() |
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Application of radiotherapy before or after local excision of rectal cancer may reduce the risk of local recurrence. However, it may have an adverse effect on bowel function. |
Emergency management of malignant large bowel obstruction (COLMNG5)
Consensus-based recommendation![]() |
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If stenting is considered, it should be discussed by the multidisciplinary team and implications for anti-VEGF systemic therapy should be assessed. |
Peritonectomy with hyperthermic intraperitoneal chemotherapy (COLMNG3)
Adjuvant therapy for colon cancer
Adjuvant therapy for stage III colon cancer
Practice point![]() |
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Oxaliplatin in combination with a fluoropyrimidine is standard therapy for young patients (< 70 years) with stage III colon cancer. |
Practice point![]() |
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Capecitabine plus oxaliplatin (XELOX) can be considered as an alternative to FOLFOX for adjuvant treatment for patients with stage III colon cancer. |
Adjuvant therapy for elderly patients with stage III colon cancer
Practice point![]() |
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The addition of oxaliplatin to adjuvant fluoropyrimidine-based therapy in elderly patients (≥ 70 years) with stage III colon cancer did not improve survival outcomes. |
Adjuvant therapy for stage II colon cancer
Practice point![]() |
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The optimal approach to adjuvant therapy in stage II colon cancer remains uncertain. Adjuvant therapy can be considered in high-risk patients on a case-by-case basis. |
Irinotecan and targeted (biological) agents in adjuvant therapy for stage II and stage III colon cancer
Practice point![]() |
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Neither Irinotecan nor a biological agent (either bevacizumab or cetuximab) should be used as adjuvant therapy for patients with stage II or III colon cancer. |
Neoadjuvant and adjuvant therapy for rectal cancer
Neoadjuvant therapy for rectal cancer
Short-course radiation treatment
Practice point![]() |
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Short-course radiation treatment should be considered if there are clear concerns regarding a patient’s physical or psychosocial ability to tolerate long-course chemoradiation. |
Neoadjuvant long-course chemoradiation
Evidence-based recommendation![]() |
Grade |
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Consider neoadjuvant chemoradiation for patients with stage II-III rectal cancer where appropriate. | C |
Practice point![]() |
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The current standard dose of neoadjuvant chemoradiation is 50–50.4 Gy (boost volume after 45 Gy) with either continuous infusional 5FU or capecitabine. |
'Watch and wait' approach after clinical complete response to neoadjuvant chemoradiation (NEO1a)
Neoadjuvant chemotherapy regimen
Practice point![]() |
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Infusional fluoropyrimidine is preferable to bolus fluoropyrimidine for use in combination with radiation treatment for rectal cancer. |
Practice point![]() |
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Oral capecitabine or intravenous infusional 5FU are both acceptable agents to combine with radiation treatment for rectal cancer. |
Practice point![]() |
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If capecitabine is considered, patients should be carefully selected to minimise risk of non-compliance or overdosing. |
Practice point![]() |
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The role of neoadjuvant systemic chemotherapy is still under investigation and is not regarded as routine. |
Optimal timing surgery after neoadjuvant therapy
Postoperative chemotherapy
Practice point![]() |
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Patients with upper third rectal tumours (10–15cm from the anal verge) with either cN+ or pN+ findings, are possibly those who may derive any/most benefit from adjuvant chemotherapy. |
Practice point![]() |
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The uncertain benefits of oxaliplatin as adjuvant therapy in rectal cancer should be acknowledged. |
Postoperative radiation treatment
Management of resectable locally recurrent disease and metastatic disease
Investigation of recurrent cancer
Management of locally recurrent resectable colorectal cancer
Consensus-based recommendation![]() |
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Patients who have not previously received radiotherapy should be considered for neoadjuvant chemoradiation prior to re-operative surgery. |
Practice point![]() |
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Patients with locally recurrent colorectal cancer should be referred to a centre with the expertise in the management of these cancers. |
Management of resectable metastatic colorectal cancer (MNG14)
Evidence-based recommendation![]() |
Grade |
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In patients with resectable liver metastases, liver resection should be offered, as this improves overall and progression free survival. | D |
Consensus-based recommendation![]() |
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In patients with pulmonary metastases, pulmonary resection improves locoregional control and may improve survival. |
Consensus-based recommendation![]() |
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Systemic adjuvant chemotherapy following complete resection of pulmonary metastases may reduce the likelihood of further systemic or local recurrences. |
Practice point![]() |
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Patients with liver metastases should be referred to a centre with expertise in the management of these malignancies, for consideration of liver resection, if appropriate. |
Management of non-resectable locally recurrent disease and metastatic disease
Liver-directed therapies for patients with incurable metastatic colorectal cancer
Practice point![]() |
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All patients with metastatic colorectal cancer should be discussed at a multidisciplinary team meeting with clinicians who have expertise in management of metastatic colorectal cancer. |
Practice point![]() |
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For patients who could be considered surgical candidates if their metastases were smaller, we suggest initial systemic chemotherapy followed by re-evaluation for surgery. |
Practice point![]() |
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Wherever possible, patients considering liver-directed therapies should be enrolled into clinical trials examining these treatments in comparison to standard therapies. |
Management of synchronous primary colorectal cancer with unresectable metastatic disease
The role of systemic therapies in non-resectable metastatic disease
Molecular pathology and biomarkers – implications for systemic therapy
Practice point![]() |
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RAS testing should be carried out on all patients at the time of diagnosis of metastatic colorectal cancer. |
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RAS mutational status is a negative predictive biomarker for therapeutic choices involving EGFR antibody therapies in metastatic colorectal cancer. |
Practice point![]() |
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Cetuximab and panitumumab should only be considered for the treatment of patients with RAS wild-type metastatic colorectal cancer. |
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The BRAF mutation status should ideally be performed at the time of diagnosis of metastatic colorectal cancer, as this represents a distinct biologic subtype. |
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The presence of a BRAF mutation in metastatic colorectal cancer is considered a poor prognostic marker. |
Practice point![]() |
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The preponderance of the available evidence is that response to EGFR-targeted agents is less likely in patients whose tumours harbour a BRAF mutation. |
Practice point![]() |
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Metastatic colorectal cancer patients with a BRAF mutation should be considered for a clinical trial where available or triplet chemotherapy if suitable. |
Practice point![]() |
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MSI testing in the metastatic setting can be useful to help identify patients who require referral for further genetic testing and counselling. |
Practice point![]() |
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BRAF V600 mutational analysis should be done in conjunction with MSI testing for prognostic stratification. |
Practice point![]() |
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MSI testing may be a predictive marker for the use of immune checkpoint inhibitors in the treatment of patients with metastatic colorectal cancer. |
Practice point![]() |
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Emerging biomarkers are not recommended for routine patient management outside of the clinical trial setting. |
Practice point![]() |
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Future trials for colon cancer should stratify patients by 'sidedness,' to better understand this issue. |
Systemic chemotherapy treatment options for first-line treatment
Practice point![]() |
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For those with good performance status and without significant comorbidities intensive triplet chemotherapy with FOLFIRINOX can be considered. |
Practice point![]() |
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Patient comorbidities, ECOG performance status, and location and burden of metastatic disease should be considered in treatment decisions. |
Practice point![]() |
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For patients who are medically unfit with poor performance status, a supportive care approach may be appropriate. |
Role of biological agents in first-line treatment of metastatic colorectal cancer
Practice point![]() |
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Biological agents targeting EGFR or VEGF in combination with chemotherapy are recommended in the first-line treatment of most patients unless contraindicated. |
Practice point![]() |
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Patients with left sided colorectal cancer should be considered for initial doublet chemotherapy and anti-EGFR therapy where appropriate. Alternate options remain appropriate based on patient preference and comorbidity.See left vs. right section |
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EGFR antibodies may be less efficacious in patients with BRAF mutations. |
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Patients with right sided colorectal cancer should be considered for initial doublet chemotherapy plus or minus anti-VEGF. See left vs. right section |
Subsequent treatment and the continuum-of-care model
Practice point![]() |
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Individualisation and discussion with the patient is essential when planning treatment breaks and or de-escalation/maintenance schedules. |
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When the combination of leucovorin calcium (folinic acid), 5-fluorouracil (5FU) and oxaliplatin (FOLFOX), with or without bevacizumab, is used for first-line therapy, the available data suggest that it is reasonable to discontinue oxaliplatin temporarily while maintaining a fluoropyrimidine with or without bevacizumab. |
Practice point![]() |
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For patients receiving initial therapy with a single-agent fluoropyrimidine (plus bevacizumab), induction therapy should be maintained. |
Practice point![]() |
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Initial induction therapy or a second-line therapy should be reintroduced at radiological or first signs of symptomatic progression. |
Systemic options for second-line treatment
Practice point![]() |
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Patients who did not receive bevacizumab as part of first-line therapy should be considered for bevacizumab in second-line therapy, in combination with a second-line cytotoxic regimen. |
Practice point![]() |
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Patients who received a first-line oxaliplatin-containing regimen should be switched to an irinotecan-containing regimen, and vice versa. |
Systemic options for third-line treatment
Practice point![]() |
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If available, regorafenib or trifluridine/tipiracil can be considered for patients with metastatic colorectal cancer refractory to all standard available therapies. |
Practice point![]() |
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Patients receiving third-line therapy should be offered participation in clinical trials, wherever available. |
Follow-up after curative resection for colorectal cancer
Rationale for follow-up
Practice point![]() |
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Patients who are unfit for further surgery or who have advanced disease require appropriate follow-up directed at psychological support and symptom relief. |
Optimal follow-up surveillance protocol
Practice point![]() |
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These recommendations apply only to asymptomatic patients. All patients who develop symptoms should be investigated rigorously. |
Practice point![]() |
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Colonoscopy should be performed at 12 months after surgery to exclude missed lesions. If the initial colonoscopy was incomplete then a colonoscopy should be performed at the latest 6 months after surgery. If the colonoscopy is normal, refer to the Clinical Practice Guidelines for Surveillance Colonoscopy for subsequent colonoscopies. |
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Intensive follow-up can detect recurrences earlier, thus surgical resection for curative intent is possible. However, this is not associated with improved survival. |
Practice point![]() |
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CEA and CT scans are readily accessible and relatively sensitive investigations. |
Health professionals performing follow-up and suggested follow-up schedule
Practice point![]() |
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Follow-up can be delivered as a combination of visits to the surgeon or associated gasteroenterologist, with ongoing care by the GP and clinical nurse consultant. |
Pyschosocial care
Psychosocial care
Practice point![]() |
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Patients with colorectal cancer should be screened for psychological distress at diagnosis and key points in their disease trajectory. |
Practice point![]() |
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Psychological interventions should be a component of colorectal cancer care, as they can improve the quality of life for patients with cancer. |
Practice point![]() |
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The use of decision aids should be considered for preference-sensitive decisions about treatment for colorectal cancer. |
- ↑ National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for guideline developers. Canberra: National Health and Medical Research Council; 2009 Available from: https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf.