Latest Guidance Updates
February 2022: This quality standard was updated and statements prioritised in 2012 were replaced. The topic was identified for update following the annual review of quality standards. The review identified updated guidance on colorectal cancer
This specialist Guidelines summary covers quality standards for the management of colorectal (bowel) cancer in adults. This includes managing local disease and secondary tumours (metastatic disease). This summary has been produced for use by oncology teams involved in the management of colorectal cancer. For information on rationales and quality measures, refer to the original quality standard (QS20) from NICE.
List of Quality Statements
Quality Statement 1: Testing for Lynch Syndrome
- Adults with a new diagnosis of colorectal cancer have testing for Lynch syndrome
- Testing for Lynch syndrome in adults with colorectal cancer uses immunohistochemistry (IHC) to test for the expression of MLH1, MSH2, MSH6 and PMS2 proteins or polymerase chain reaction (PCR) to test for microsatellite instability to identify tumours with deficient DNA mismatch repair. Results from these tests guide further sequential testing for Lynch syndrome. Further testing includes testing for BRAF V600E mutation, and if this is negative, testing for MLH1 promoter hypermethylation. Lynch syndrome can be confirmed by genetic testing of germline DNA. (Adapted from NICE's diagnostics guidance on molecular testing strategies for Lynch syndrome in people with colorectal cancer, and expert opinion)
- Test results suggestive of Lynch syndrome-associated colorectal cancer:
- Abnormal MLH1 expression by IHC or microsatellite instability, and negative tests for BRAF V600E and MLH1 promoter hypermethylation, or abnormal MSH2, MSH6 or PMS2 expression on IHC. (Adapted from NICE's diagnostics guidance on molecular testing strategies for Lynch syndrome in people with colorectal cancer)
- Healthcare professionals (such as gastroenterologists, colorectal surgeons and consultant histopathologists) are aware of local protocols to ensure that adults with a new diagnosis of colorectal cancer have testing for Lynch syndrome. Healthcare professionals are aware of referral pathways and can identify when to refer to clinical genetics services for the diagnosis of Lynch syndrome.
Quality Statement 2: Discussion About Treatment Options for Early Rectal Cancer
- Adults with early rectal cancer discuss the implications of all potential treatment options with their healthcare professional
- Healthcare professionals (such as colorectal cancer specialists) clearly explain all potential treatment options for early rectal cancer including endoscopic procedures, minimally invasive local surgical procedures and rectal resection. They give information on non-surgical procedures, the option of no treatment and relevant clinical trials. They discuss the implications of each of the options with adults with early rectal cancer before reaching a shared decision about the best option for them.
Quality Statement 3: Testing to Guide Systemic Anti-Cancer Treatment
- Adults with metastatic colorectal cancer suitable for systemic anti‑cancer treatment have testing to identify tumours with RAS and BRAF V600E mutations
- Healthcare professionals (such as oncologists) are aware of local referral pathways for testing to identify tumours with RAS and BRAF V600E mutations in adults with metastatic colorectal cancer suitable for systemic anti-cancer treatment.
Quality Statement 4: Follow-Up for Detecting Local Recurrence and Distant Metastases
- Adults who have had potentially curative surgical treatment for non‑metastatic colorectal cancer have follow-up for the first 3 years to detect local recurrence and distant metastases
- Follow-up to detect local recurrence and distant metastases includes measurement of serum carcinoembryonic antigen (CEA) at least every 6 months and a minimum of 2 computed tomography (CT) scans of the chest, abdomen, and pelvis in the first 3 years. Clearance colonoscopy should be done within a year a diagnosis. (Adapted from NICE's guideline for colorectal cancer, and evidence review E1, and BSG/ACPGBI/PHE post-polypectomy and post-colorectal cancer resection surveillance guidelines (2020), page 207)
- Healthcare professionals (such as colorectal cancer nurse specialists) are aware of local pathways and clinical protocols for follow-up of adults who have had potentially curative surgery for non-metastatic colorectal cancer. They ensure that these adults have regular testing of serum CEA, CT scans and colonoscopy in the first 3 years after potentially curative surgery.
Related Quality Statement
Statement 3 on testing for blood in faeces from NICE's quality standard on suspected cancer is relevant to this quality standard and should also be considered when commissioning or providing colorectal cancer services.