Colorectal Cancer in Secondary Care

This specialist Guidelines summary covers managing colorectal (bowel) cancer in people aged 18 and over. It aims to improve quality of life and survival for adults with colorectal cancer through management of local disease and secondary tumours (metastatic disease). This summary is for use by medical and clinical oncologists in a secondary care setting.

Please refer to the full guideline for information on surgery for people with rectal cancer and surgical technique for people with colon cancer

A table of NHS England interim treatment regimens gives possible alternative treatment options for use during the COVID-19 pandemic to reduce infection risk. This may affect decisions for patients with prostate cancer. See the COVID-19 rapid guideline: delivery of systemic anticancer treatments for more details.

Reduction in Risk of Colorectal Cancer in People with Lynch Syndrome

• Consider daily aspirin, to be taken for more than 2 years, to reduce the risk of colorectal cancer in people with Lynch syndrome.
  In January 2020 this was an off-label use of aspirin. See NICE's information on prescribing medicines.

Information for People with Colorectal Cancer

• Provide people with colorectal cancer information about their treatment (both written and spoken) in a sensitive and timely manner throughout their care, tailored to their needs and circumstances. Make sure the information is relevant to them, based on the treatment they might have and the possible side effects. Also see the NICE guidelines on patient experience in adult NHS services and decision-making and mental capacity.
• Give people information on all treatment options for colorectal cancer available to them, including:
  • surgery, radiotherapy, systemic anti-cancer therapy, or palliative care
  • the potential benefits, risks, side effects, and implications of treatments, for example, possible effects on bowel and sexual function (see also the section on Management of low anterior resection syndrome), quality of life, and independence.
• Advise people with colorectal cancer of possible reasons why their treatment plan might need to change during their care, including:
  • changes from laparoscopic to open surgery or curative to non-curative treatment, and why this change may be the most suitable option for them
  • the likelihood of having a stoma, why it might be necessary, and for how long it might be needed.
• If recovery protocols (such as 'enhanced recovery after surgery', ERAS) are used, explain to people with colorectal cancer what these involve and their value in improving their recovery after surgery.
• Ensure that appropriate specialists discuss possible side effects with people who have had surgery for colorectal cancer, including:
  • altered bowel, urinary, and sexual function
    physical changes, including anal discharge or bleeding.
    
    If relevant, have a trained stoma professional provide information on the care and management of stomas and on learning to live with a stoma.
• Emphasise to people the importance of monitoring and managing side effects during non-surgical treatment to try to prevent permanent damage (for example, monitoring prolonged sensory symptoms after platinum-based chemotherapy treatment, which can be a sign that the dose needs to be reduced to minimise future permanent peripheral neuropathy).
• Give people who have had treatments for colorectal cancer information about possible short-term, long-term, permanent, and late side effects which can affect quality of life, including:
  • pain
  • altered bowel, urinary, or sexual function
  • nerve damage and neuropathy
  • mental and emotional changes, including anxiety, depression, chemotherapy-related cognitive impairment, and changes to self-perception and social identity.
• Prepare people for discharge after treatment for colorectal cancer by giving them advice on:
  • adapting physical activity to maintain their quality of life
  • diet, including advice on foods that can cause or contribute to bowel problems such as diarrhoea, flatulence, incontinence, and difficulty in emptying the bowels
  • weight management, physical activity, and healthy lifestyle choices (for example stopping smoking and reducing alcohol use)
  • how long their recovery might take
  • how, when, and where to seek help if side effects become problematic.

Management of Local Disease

People with Rectal Cancer

Treatment for People with Early Rectal Cancer (cT1-T2, cN0, M0)

• Offer one of the treatments shown in Table 1 to people with early rectal cancer (cT1-T2, cN0, M0) after discussing the implications of each treatment and reaching a shared decision with the person about the best option.

Table 1: Implications of Treatments for Early Rectal Cancer (cT1-T2, cN0, M0)

Preoperative Treatment for People with Rectal Cancer

• Do not offer preoperative radiotherapy to people with early rectal cancer (cT1-T2 cN0, M0), unless as part of a clinical trial.
• Offer preoperative radiotherapy or chemoradiotherapy to people with rectal cancer that is cT1-T2, cN1-N2, M0, or cT3-T4, any cN, M0.

Surgery for People with Rectal Cancer

• Offer surgery to people with rectal cancer (cT1-T2, cN1-N2, M0, or cT3-T4, any cN, M0) who have a resectable tumour.
• Inform people with a complete clinical and radiological response to neoadjuvant treatment who wish to defer surgery that there is a risk of recurrence, and there are no prognostic factors to guide selection for deferral of surgery. For those who choose to defer, encourage their participation in a clinical trial and ensure that data is collected via a national registry.

People with Locally Advanced or Recurrent Rectal Cancer

• Consider referring people with locally advanced primary or recurrent rectal cancer that might potentially need multi-visceral or beyond-TME surgery to a specialist centre to discuss exenterative surgery.

People with Colon Cancer

• Consider preoperative systemic anti-cancer therapy for people with cT4 colon cancer.

People with Either Colon or Rectal Cancer

Duration of Adjuvant Chemotherapy for People with Colorectal Cancer

• For people with stage III colon cancer (pT1-4, pN1-2, M0), or stage III rectal cancer (pT1-4, pN1-2, M0) treated with short-course radiotherapy or no preoperative treatment, offer:
  • capecitabine in combination with oxaliplatin (CAPOX) for 3 months, or if this is not suitable
  • oxaliplatin in combination with 5-fluorouracil and folinic acid (FOLFOX) for 3 to 6 months, or
  • single-agent fluoropyrimidine (for example, capecitabine) for 6 months, in line with NICE technology appraisal guidance (see the NICE technology appraisal guidance on the topic page on colorectal cancer).
    Base the choice on the person's histopathology (for example pT1-T3 and pN1, and pT4 and/or pN2), performance status, any comorbidities, age, and personal preferences.
    In January 2020, the use of some treatments was off label:
  • oxaliplatin in combination with capecitabine (though CAPOX is common in UK clinical practice)
  • capecitabine for 3 months duration of adjuvant treatment in people with colon cancer
  • CAPOX and FOLFOX in stage III rectal cancer.
    See NICE's information on prescribing medicines.

Colonic Stents in Acute Large Bowel Obstruction

• Consider stenting for people presenting with acute left-sided large bowel obstruction who are to be treated with palliative intent.
• Offer either stenting or emergency surgery for people presenting with acute left-sided large bowel obstruction if potentially curative treatment is suitable for them.

Molecular Biomarkers to Guide Systemic Anti-cancer Treatment

• Test for RAS and BRAF V600E mutations in all people with metastatic colorectal cancer suitable for systemic anti-cancer treatment.

Management of Metastatic Disease

People with Asymptomatic Primary Tumour

• Consider surgical resection of the primary tumour for people with incurable metastatic colorectal cancer who are receiving systemic anti-cancer therapy and have an asymptomatic primary tumour. Discuss the implications of the treatment options with the person before making a shared decision. See Table 2.

Table 2: Factors to Take Into Account When Considering resection of the Asymptomatic Primary Tumour

Systemic Anti-cancer Therapy for People with Metastatic Colorectal Cancer

• For advice on systemic anti-cancer therapy for people with metastatic cancer, see NICE technology appraisal guidance on the topic page on colorectal cancer.

Genomic Biomarker-based Treatment

People with Metastatic Colorectal Cancer in the Liver

• Consider resection, either simultaneous or sequential, after discussion by a multidisciplinary team with expertise in resection of disease in all involved sites.
• Consider perioperative systemic anti-cancer therapy if liver resection is a suitable treatment.
• Consider chemotherapy with local ablative techniques for people with colorectal liver metastases that are unsuitable for liver resection after discussion by a specialist multidisciplinary team.
• Do not offer selective internal radiation therapy (SIRT) as first-line treatment for people with colorectal liver metastases that are unsuitable for local treatment. See the NICE interventional procedures guidance on selective internal radiation therapy for unresectable colorectal metastases in the liver, which recommends that SIRT should only be offered:
  • with special arrangements for clinical governance, consent, and audit or research to people who are chemotherapy intolerant or who have liver metastases that are refractory to chemotherapy
  • in the context of research to people who can have chemotherapy.

People with Metastatic Colorectal Cancer in the Lung

• Consider metastasectomy, ablation, or stereotactic body radiation therapy for people with lung metastases that are suitable for local treatment, after discussion by a multidisciplinary team that includes a thoracic surgeon and a specialist in non-surgical ablation.
• Consider biopsy for people with a single lung lesion to exclude primary lung cancer.

People with Metastatic Colorectal Cancer in the Peritoneum

• For people with colorectal cancer metastases limited to the peritoneum:
  • offer systemic anti-cancer therapy and
  • within a multidisciplinary team, discuss referral to a nationally commissioned specialist centre to consider cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).

Ongoing Care and Support

Follow-up for Detection of Local Recurrence and Distant Metastases

• For people who have had potentially curative surgical treatment for non-metastatic colorectal cancer, offer follow-up for detection of local recurrence and distant metastases for the first 3 years. Follow-up should include serum carcinoembryonic antigen (CEA) and CT scan of the chest, abdomen, and pelvis.

Management of Low Anterior Resection Syndrome

• Give information on low anterior resection syndrome (LARS) to people who will potentially have sphincter-preserving surgery. Advise them to seek help from primary care if they think they have symptoms of LARS, such as:
  • increased frequency of stool
  • urgency with or without incontinence of stool
  • feeling of incomplete emptying
  • fragmentation of stool (passing small amounts little and often)
  • difficulty in differentiating between gas and stool.
• Assess people with symptoms of LARS using a validated patient-administered questionnaire (for example, the Low Anterior Resection Syndrome score (LARS score), at the European Society of Coloproctology).
• Offer people with bowel dysfunction treatment for associated symptoms in primary care (such as dietary management, laxatives, anti-bulking agents, anti-diarrhoeal agents, or anti-spasmodic agents). Seek advice from secondary care if the treatment is not successful.