Colorectal cancer

Short Text

The diagnosis and management of colorectal cancer

Introduction

This pathway covers the diagnosis and management of colorectal cancer. Colorectal cancer is the third most common cancer in the UK after breast and lung cancer, with approximately 40,000 new cases registered each year. Occurrence of colorectal cancer is strongly related to age, with almost three-quarters of cases occurring in people aged 65 or over. Colorectal cancer is the second most common cause of cancer death in the UK.
Around half of people diagnosed with colorectal cancer survive for at least 5 years after diagnosis.

Source guidance

The NICE guidance that was used to create the pathway.
Colorectal cancer. NICE clinical guideline 131 (2011)
Cetuximab for the first-line treatment of metastatic colorectal cancer. NICE technology appraisal guidance 176 (2009)
Laparoscopic surgery for colorectal cancer. NICE technology appraisal guidance 105 (2006)

Quality standards

Colorectal cancer quality standard

These quality statements are taken from the colorectal cancer quality standard. The quality standard defines clinical best practice in colorectal cancer care and should be read in full.

Quality statements

Colonoscopy

This quality statement is taken from the colorectal cancer quality standard. The quality standard defines clinical best practice in colorectal cancer care and should be read in full.

Quality statement

People with suspected colorectal cancer without major comorbidity are offered diagnostic colonoscopy.

Quality measure

Structure
Evidence of local arrangements to ensure people with suspected colorectal cancer without major comorbidity are offered diagnostic colonoscopy.
Process
Proportion of people with suspected colorectal cancer without major comorbidity who receive diagnostic colonoscopy.
Numerator – the number of people in the denominator who receive diagnostic colonoscopy.
Denominator – the number of people with suspected colorectal cancer without major comorbidity.

What the quality statement means for each audience

Service providers ensure systems are in place for people with suspected colorectal cancer without major comorbidity to be offered diagnostic colonoscopy.
Healthcare professionals ensure they offer diagnostic colonoscopy to people with suspected colorectal cancer without major comorbidity.
Commissioners ensure they commission services for people with suspected colorectal cancer without major comorbidity that offer diagnostic colonoscopy.
People with suspected colorectal cancer without any other significant diseases are offered a procedure called colonoscopy, which allows the large bowel to be viewed through a camera on the end of a flexible tube, to establish the diagnosis.

Source guidance

NICE clinical guideline 131 recommendations 1.1.1.2 (key priority for implementation) and 1.1.1.1.

Data source

Structure
Local data collection.
Process
Local data collection. The National Bowel Cancer Audit records colonoscopy results, classified as abnormal (cancer detected whether complete examination or not), inadequate (no cancer detected but incomplete examination), not done or not known. The NHS Bowel Cancer Screening Programme's Quality assurance guidelines for colonoscopy suggest indicators based on data returns, including:
  • minimum number of screening colonoscopies
  • bowel preparation
  • response rate (acceptance rate) for colonoscopy (index and surveillance)
  • surveillance colonoscopy attendance rate
  • consent
  • safe sedation and comfort
  • caecal intubation rate
  • neoplasia detection rates
  • withdrawal time in negative colonoscopies
  • polyp recovery.
Also contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): Diagnosis, criteria 1 and 2.

Definitions

NICE clinical guideline 131 (full version) concludes that colonoscopy is the most effective investigation for diagnosis of colorectal tumours. It also allows immediate biopsy confirmation of colorectal cancer and removal of adenomas during the same procedure. Therefore, the guideline recommends colonoscopy as the first investigation for the diagnosis of colorectal tumours.
NICE clinical guideline 131 (full version) recognises it may not be possible to perform complete colonoscopy in some patients. Also, patients with serious cardiorespiratory or neurological comorbidity may be at high risk from potential complications of colonoscopy (for example colonic perforation or the effects of sedation). Such patients might be better served by alternative investigations.

Staging (colon cancer)

This quality statement is taken from the colorectal cancer quality standard. The quality standard defines clinical best practice in colorectal cancer care and should be read in full.

Quality statement

People with colon cancer are offered contrast-enhanced computed tomography (CT) of the chest, abdomen and pelvis to determine the stage of the disease.

Quality measure

Structure
Evidence of local arrangements to ensure people with colon cancer are offered contrast-enhanced CT of the chest, abdomen and pelvis to determine the stage of the disease.
Process
Proportion of people with colon cancer who receive contrast-enhanced CT of the chest, abdomen and pelvis to determine the stage of the disease.
Numerator – the number of people in the denominator who receive contrast-enhanced CT of the chest, abdomen and pelvis to determine the stage of the disease.
Denominator – the number of people with colon cancer without contraindications to contrast-enhanced CT of the chest, abdomen and pelvis.

What the quality statement means for each audience

Service providers ensure systems are in place for people with colon cancer to be offered contrast-enhanced CT of the chest, abdomen and pelvis to determine the stage of the disease.
Healthcare professionals offer people with colon cancer contrast-enhanced CT of the chest, abdomen and pelvis to determine the stage of the disease.
Commissioners ensure they commission services that offer people with colon cancer contrast-enhanced CT of the chest, abdomen and pelvis to determine the stage of the disease.
People with colon cancer are offered a CT scan of the chest, abdomen and pelvis to estimate the spread of the disease.

Source guidance

NICE clinical guideline 131 recommendation 1.1.2.1 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. The National Bowel Cancer Audit records CT scan results, classified as normal liver, liver metastases or liver uncertain. Also contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): Staging, criterion 1.

Staging (rectal cancer)

This quality statement is taken from the colorectal cancer quality standard. The quality standard defines clinical best practice in colorectal cancer care and should be read in full.

Quality statement

People with rectal cancer are offered contrast-enhanced computed tomography (CT) of the chest, abdomen and pelvis to determine the stage of the disease, and pelvic magnetic resonance imaging (MRI) to assess the risk of local recurrence.

Quality measure

Structure
Evidence of local arrangements to ensure people with colorectal cancer are offered contrast-enhanced CT of the chest, abdomen and pelvis to determine the stage of the disease, and pelvic MRI to assess the risk of local recurrence.
Process
Proportion of people with rectal cancer who receive contrast-enhanced CT of the chest, abdomen and pelvis to determine the stage of the disease, and pelvic MRI to assess the risk of local recurrence.
Numerator – the number of people in the denominator who receive contrast-enhanced CT of the chest, abdomen and pelvis to determine the stage of the disease, and pelvic MRI to assess the risk of local recurrence.
Denominator – the number of people with rectal cancer without contraindications to CT of the chest, abdomen and pelvis or pelvic MRI.

What the quality statement means for each audience

Service providers ensure systems are in place for people with rectal cancer to be offered contrast-enhanced CT of the chest, abdomen and pelvis to determine the stage of the disease, and pelvic MRI to assess the risk of local recurrence.
Healthcare professionals ensure they offer people with rectal cancer contrast-enhanced CT of the chest, abdomen and pelvis to determine the stage of the disease, and pelvic MRI to assess the risk of local recurrence.
Commissioners ensure they commission services that offer people with rectal cancer contrast-enhanced CT of the chest, abdomen and pelvis to determine the stage of the disease, and pelvic MRI to assess the risk of local recurrence.
People with rectal cancer are offered a CT scan of the chest, abdomen and pelvis to estimate the spread of the disease, and an MRI scan to assess the risk of the cancer returning.

Source guidance

NICE clinical guideline 131 recommendations 1.1.2.1 and 1.1.2.2 (key priorities for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. The National Bowel Cancer Audit records CT scan results, classified as normal liver, liver metastases or liver uncertain, and also records MRI scans. Also contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): Staging, criteria 1 and 2.

Preoperative treatment of rectal cancer

This quality statement is taken from the colorectal cancer quality standard. The quality standard defines clinical best practice in colorectal cancer care and should be read in full.

Quality statement

People with rectal cancer are offered a preoperative treatment strategy appropriate to their risk of local disease recurrence.

Quality measure

Structure
Evidence of local arrangements, including written clinical protocols, to ensure people with rectal cancer are offered a preoperative treatment strategy appropriate to their risk of local disease recurrence.
Process
a) Proportion of people with low-risk operable rectal cancer who do not receive short-course preoperative radiotherapy or chemoradiotherapy unless as part of a clinical trial.
Numerator – the number of people in the denominator who do not receive short-course preoperative radiotherapy or chemoradiotherapy, unless as part of a clinical trial.
Denominator – the number of people with low-risk operable rectal cancer.
b) Proportion of people with high-risk operable rectal cancer who receive preoperative chemoradiotherapy with a suitable interval before surgery to allow tumour response and shrinkage.
Numerator – the number of people in the denominator who receive preoperative chemoradiotherapy with a suitable interval before surgery to allow tumour response and shrinkage.
Denominator – the number of people with high-risk operable rectal cancer.
c) Proportion of people with high-risk locally advanced rectal cancer who receive preoperative chemoradiotherapy with a suitable interval before surgery to allow tumour response and shrinkage.
Numerator – the number of people in the denominator who receive preoperative chemoradiotherapy with a suitable interval before surgery to allow tumour response and shrinkage.
Denominator – the number of people with high-risk locally advanced rectal cancer.
Outcome
a) Local recurrence.
b) Circumferential resection margin.

What the quality statement means for each audience

Service providers ensure systems are in place for people with rectal cancer to be offered a preoperative treatment strategy appropriate to their risk of local disease recurrence.
Healthcare professionals offer people with rectal cancer a preoperative treatment strategy appropriate to their risk of local disease recurrence.
Commissioners ensure they commission services that offer people with rectal cancer a preoperative treatment strategy appropriate to their risk of local disease recurrence.
People with rectal cancer are offered treatment before surgery that takes into account the likelihood of the cancer returning.

Source guidance

NICE clinical guideline 131 recommendations 1.2.1.2 (key priority for implementation), 1.2.1.3, 1.2.1.4, 1.2.1.6 and 1.2.1.7.

Data source

Structure
Local data collection.
Process
a), b) and c) The National Bowel Cancer Audit records preoperative radiotherapy.
a) Local data collection. Contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): Management of local disease – preoperative management of the primary tumour, criterion 2.
b) Local data collection. Contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): Management of local disease – preoperative management of the primary tumour, criterion 3.
c) Local data collection. Contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): Management of local disease – preoperative management of the primary tumour, criterion 5.
Outcome
a) Local data collection.
b) The National Bowel Cancer Audit records whether the circumferential margin was involved, not involved or not known. It also records the distance between the cancer and the circumferential margins.

Definitions

NICE clinical guideline 131 uses the following categorisations of risk of local disease recurrence:
  • High – a threatened (less than 1 mm) or breached resection margin; or low tumours encroaching onto the inter-sphincteric plane or with levator involvement.
  • Moderate – any cT3b or greater, in which the potential surgical margin is not threatened; or any suspicious lymph node not threatening the surgical resection margin; or the presence of extramural vascular invasion (this feature is also associated with high risk of systemic recurrence).
  • Low – cT1, cT2 or cT3a and no lymph node involvement.
NICE clinical guideline 131 also uses the following categorisations:
  • Low-risk operable rectal cancer – primary rectal tumours which appear resectable at presentation.
  • High-risk operable rectal cancer – primary rectal tumours which appear resectable at presentation.
  • High-risk locally advanced rectal cancer – primary rectal tumours which appear unresectable or borderline resectable.

Stage I colorectal cancer treatment

This quality statement is taken from the colorectal cancer quality standard. The quality standard defines clinical best practice in colorectal cancer care and should be read in full.

Quality statement

People with locally excised, pathologically confirmed stage I colorectal cancer whose tumour had involved resection margins (less than 1 mm) are offered further surgery or active monitoring.

Quality measure

Structure
Evidence of local arrangements, including written clinical protocols, to ensure people with locally excised, pathologically confirmed stage I colorectal cancer whose tumour had involved resection margins (less than 1 mm), are offered further surgery or active monitoring.
Process
Proportion of people with locally excised, pathologically confirmed stage I colorectal cancer whose tumour had involved resection margins (less than 1 mm), who receive further surgery or active monitoring.
Numerator – the number of people in the denominator who receive further surgery or active monitoring.
Denominator – the number of people with locally excised, pathologically confirmed stage I colorectal cancer whose tumour had involved resection margins (less than 1 mm).

What the quality statement means for each audience

Service providers ensure systems are in place for people with locally excised, pathologically confirmed stage I colorectal cancer whose tumour had involved resection margins (less than 1 mm) to be offered further surgery or active monitoring.
Healthcare professionals ensure people with locally excised, pathologically confirmed stage I colorectal cancer whose tumour had involved resection margins (less than 1 mm) are offered further surgery or active monitoring.
Commissioners ensure they commission services where people with locally excised, pathologically confirmed stage I colorectal cancer whose tumour had involved resection margins (less than 1 mm) are offered further surgery or active monitoring.
People with colorectal cancer that has not spread beyond the original tumour (stage I), as confirmed by examining the tumour once it is removed, are offered further surgery or active monitoring if the healthy tissue around the tumour is thought to contain cancer cells.

Source guidance

NICE clinical guideline 131 recommendations 1.2.3.1 (key priority for implementation) and 1.2.3.2.

Data source

Structure
Local data collection.
Process
Local data collection. Local data collection. The National Bowel Cancer Audit reports on whether the circumferential margin was involved, not involved or not known. It also records the distance between the cancer and the circumferential margins. Also contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): Management of local disease – stage I colorectal cancer, criterion 1.

Definitions

NICE clinical guideline 131 (full version) states that although it is extremely important for patients with involved resection margins to be offered further treatment, there was not enough evidence to recommend specific treatments. Therefore the decision on which further treatment to use should be made locally by the appropriate multidisciplinary team.
NICE clinical guideline 131 states that the colorectal multidisciplinary team should take into account pathological characteristics of the lesion, imaging results and previous treatments when deciding whether to offer further treatment.
The Topic Expert Group who developed the quality standard felt that the choice between surgery and active monitoring would be dependent on clinical judgement on the risks of surgery (taking into account factors such as age and comorbidities) and the risk of disease recurrence.
Involved resection margins (less than 1 mm) refer to the distance from tumour to nearest surgical margin.

Imaging hepatic metastases

This quality statement is taken from the colorectal cancer quality standard. The quality standard defines clinical best practice in colorectal cancer care and should be read in full.

Quality statement

People with a contrast-enhanced computed tomography (CT) of the chest, abdomen and pelvis suggesting liver metastatic colorectal cancer have their scans reviewed by the hepatobiliary multidisciplinary team to decide whether further imaging is needed to confirm suitability for surgery.

Quality measure

Structure
Evidence of local arrangements to ensure people with a contrast-enhanced CT of the chest, abdomen and pelvis suggesting liver metastatic colorectal cancer have their scans reviewed by the hepatobiliary multidisciplinary team to decide whether further imaging is needed to confirm suitability for surgery.
Process
Proportion of people with a contrast-enhanced CT of the chest, abdomen and pelvis suggesting liver metastatic colorectal cancer who have their scans reviewed by the hepatobiliary multidisciplinary team to decide whether further imaging is needed to confirm suitability for surgery.
Numerator – the number of people in the denominator who have their scans reviewed by the hepatobiliary multidisciplinary team to decide whether further imaging is needed to confirm suitability for surgery.
Denominator – the number of people with a contrast-enhanced CT of the chest, abdomen and pelvis suggesting liver metastatic colorectal cancer.

What the quality statement means for each audience

Service providers ensure systems are in place for people with a contrast-enhanced CT of the chest, abdomen and pelvis suggesting liver metastatic colorectal cancer to have their scans reviewed by the hepatobiliary multidisciplinary team to decide whether further imaging is needed to confirm suitability for surgery.
Healthcare professionals ensure people with a contrast-enhanced CT of the chest, abdomen and pelvis suggesting liver metastatic colorectal cancer have their scans reviewed by the hepatobiliary multidisciplinary team to decide whether further imaging is needed to confirm suitability for surgery.
Commissioners ensure they commission services for people with a contrast-enhanced CT of the chest, abdomen and pelvis suggesting liver metastatic colorectal cancer to have their scans reviewed by the hepatobiliary multidisciplinary team to decide whether further imaging is needed to confirm suitability for surgery.
People with colorectal cancer that may have spread to the liver have their CT scans reviewed by the hepatobiliary multidisciplinary team to decide if further scans are needed to guide the choice of treatment.

Source guidance

NICE clinical guideline 131 recommendation 1.3.2.1 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. The National Bowel Cancer Audit records CT scan results, classified as normal liver, liver metastases or liver uncertain. Also contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): Management of metastatic disease, criterion 2.

Definitions

NICE clinical guideline 131 (full version) finds that the available evidence is unclear about which form of imaging should be used after a CT scan to confirm if the patient with liver metastases is suitable for surgery. Therefore, the guideline recommends that the opinion of a hepatobiliary MDT is sought. This would allow a specialist to make the decision on what additional imaging to use, striking a balance between missing patients with resectable disease and excessive inappropriate laparotomies.

Systemic anticancer therapy

This quality statement is taken from the colorectal cancer quality standard. The quality standard defines clinical best practice in colorectal cancer care and should be read in full.

Quality statement

People with locally advanced or metastatic colorectal cancer whose disease progresses after first-line systemic anticancer therapy are offered second-line systemic anticancer therapy if they are able to tolerate it.

Quality measure

Structure
Evidence of local arrangements, including written clinical protocols, to ensure people with locally advanced or metastatic colorectal cancer whose disease progresses after first-line systemic anticancer therapy are offered second-line systemic anticancer therapy if they are able to tolerate it.
Process
Proportion of people with locally advanced or metastatic colorectal cancer whose disease progresses after first-line systemic anticancer therapy who are offered second-line systemic anticancer therapy if they are able to tolerate it.
Numerator – the number of people in the denominator who receive second-line systemic anticancer therapy.
Denominator – the number of people with locally advanced or metastatic colorectal cancer whose disease progresses after first-line systemic anticancer therapy who are able to tolerate second-line systemic anticancer therapy.
Outcome
a) 1-year survival.
b) 2-year survival.

What the quality statement means for each audience

Service providers ensure systems are in place for people with locally advanced or metastatic colorectal cancer whose disease progresses after first-line systemic anticancer therapy to be offered second-line systemic anticancer therapy if they are able to tolerate it.
Healthcare professionals offer second-line systemic anticancer therapy to people with locally advanced or metastatic colorectal cancer whose disease progresses after first-line systemic anticancer therapy if they are able to tolerate it.
Commissioners ensure they commission services for people with locally advanced or metastatic colorectal cancer whose disease progresses after first-line systemic anticancer therapy that offer second-line systemic anticancer therapy if they are able to tolerate it.
People with colorectal cancer that has spread to other parts of the body and continues to spread after initial chemotherapy are offered additional chemotherapy and/or treatment with a type of drug called a biological therapy (which may help the body to control the growth of cancer cells) if they are fit and able enough.

Source guidance

NICE clinical guideline 131 recommendations 1.3.4.1 (key priority for implementation), 1.3.4.2, 1.3.4.3 and 1.3.4.5.

Data source

Structure
Local data collection.
Process
Local data collection. The National Bowel Cancer Audit records drug treatment intent classified as palliative, adjuvant, neo-adjuvant or other. The Systemic Anti-Cancer Therapy (SACT) dataset will record clinical management information on patients undergoing chemotherapy in (or funded by) the NHS in England, and will have a staged implementation of national collection of the dataset, which began April 2012 and will have full data collection from April 2014. Also contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): chemotherapy for advanced and metastatic colorectal cancer criteria 1–5.
Outcome
a) Local data collection. The Health and Social Care Information Centre's Indicator Portal records 1-year relative survival following diagnosis of colon cancer.
b) Local data collection.

Definitions

Systemic anticancer therapy includes the use of chemotherapy and biological agents. NICE clinical guideline 131, section 1.3.4 contains recommendations on chemotherapy regimens and biological agents, including references to several NICE technology appraisals, and highlights that any decision should only be made after full discussion of the side effects and the patient's preferences.

Follow-up and regular surveillance

This quality statement is taken from the colorectal cancer quality standard. The quality standard defines clinical best practice in colorectal cancer care and should be read in full.

Quality statement

People free from disease after treatment for colorectal cancer are offered regular surveillance.

Quality measure

Structure
Evidence of local arrangements to ensure people free from disease after treatment for colorectal cancer, are offered regular surveillance.
Process
a) Proportion of people free from disease after treatment for colorectal cancer who receive 6-monthly blood carcinoembryonic antigen estimation (CEA) for 3 years after treatment.
Numerator – the number of people in the denominator who received CEA estimation no more than 6 months ago.
Denominator – the number of people who have been free from disease for 3 years or less after treatment for colorectal cancer.
b) Proportion of people free from disease after treatment for colorectal cancer who receive at least 2 CT scans of the chest, abdomen and pelvis within 3 years of treatment for colorectal cancer.
Numerator – the number of people in the denominator who received at least 2 CT scans of the chest, abdomen and pelvis within 3 years of completion of treatment.
Denominator – the number of people who have had colorectal cancer who have been disease free for 3 years or more after completion of treatment.
c) Proportion of people free from disease after treatment for colorectal cancer who receive surveillance colonoscopy 1 year after treatment.
Numerator – the number of people in the denominator who receive surveillance colonoscopy 1 year after treatment.
Denominator – the number of people free from disease for 1 year after treatment for colorectal cancer.

What the quality statement means for each audience

Service providers ensure systems are in place for people free from disease after treatment for colorectal cancer to be offered regular surveillance.
Healthcare professionals offer regular surveillance to people free from disease after treatment for colorectal cancer.
Commissioners ensure they commission services for people free from disease after treatment for colorectal cancer that offers regular surveillance.
People with colorectal cancer who are disease free after treatment are offered regular check-ups and investigations to check for any signs of the disease returning.

Source guidance

NICE clinical guideline 131 recommendations 1.4.1.2 (key priority for implementation), 1.4.1.1, 1.4.1.3, 1.4.1.4 and 1.4.1.5.

Data source

Structure
Local data collection.
Process
a), b) and c) The National Bowel Cancer Audit records data on follow-up, however these data are not currently included in the annual reports.
a) and b) Local data collection. Contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): ongoing care and support, criterion 2.
c) Local data collection. Contained within NICE audit support for colorectal cancer (NICE clinical guideline 131): ongoing care and support, criterion 3.

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Information about colorectal cancer

Information about drug treatments

Information about surgery and other procedures

Information about NICE's quality standard

NICE has also written a document for patients and the public explaining its quality standard for colorectal cancer.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

24 March 2014 'Aflibercept in combination with irinotecan and fluorouracil-based therapy for treating metastatic colorectal cancer that has progressed following prior oxaliplatin-based chemotherapy' (NICE technology appraisal guidance 307) added to second-line agents in the managing advanced and metastatic colorectal cancer path, and 'Panitumumab in combination with chemotherapy for the treatment of metastatic colorectal cancer (terminated appraisal)' (NICE technology appraisal 240) added to first-line agents and second-line agents in the managing advanced and metastatic colorectal cancer path.
9 August 2013 Minor maintenance updates.
25 June 2013 'SonoVue for contrast-enhanced ultrasound imaging of the liver' (NICE diagnostics guidance 5) added to staging assessment.
30 October 2012 Minor maintenance updates.
23 October 2012 'Denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours' (NICE technology appraisal guidance 265) added to extra-hepatic metastasis.
28 August 2012 Minor maintenance updates.
24 August 2012 Colorectal cancer quality standard added to pathway.
28 February 2012 Correct link added for 'Implementing early rectal cancer multidisciplinary teams in secondary care' case study in deciding whether to offer further treatment. Implementation tool 'Clinical case scenarios for secondary care – mixed chemotherapy options' added to chemotherapy.
31 January 2012 Cetuximab (monotherapy or combination chemotherapy), bevacizumab (in combination with non-oxaliplatin chemotherapy) and panitumumab (monotherapy) for the treatment of metastatic colorectal cancer after first-line chemotherapy (review of technology appraisal 150 and part review of technology appraisal guidance 118) (NICE technology appraisal guidance 242) added to biological agents.

Supporting information

Risk of local recurrence for rectal tumours as predicted by MRI

Risk of local recurrence
Characteristics of rectal tumours predicted by MRI
High
A threatened (< 1 mm) or breached resection margin or
Low tumours encroaching onto the inter-sphincteric plane or with levator involvement
Moderate
Any cT3b or greater, in which the potential surgical margin is not threatened or
Any suspicious lymph node not threatening the surgical resection margin or
The presence of extramural vascular invasionThis feature is also associated with high risk of systemic recurrence
Low
cT1 or cT2 or cT3a and
No lymph node involvement

Information about stomas

Before surgery, offer all patients information about the likelihood of having a stoma, why it might be necessary, and how long it might be needed for.
Ensure a trained stoma professional gives specific information on the care and management of stomas to all patients considering surgery that might result in a stoma.

Glossary

5-fluorouracil
Computed tomography
Tumour invades submucosa as clinically defined
Tumour invades muscularis propria as clinically defined
Less than 1mm invasion to mesorectum
1–5mm invasion into mesorectum
Folinic acid plus fluorouracil plus irinotecan
Folinic acid plus fluorouracil plus oxaliplatin
Hyperthermic intraoperative peritoneal chemotherapy
Magnetic resonance imaging
Multidisciplinary team
Positron emission tomographic computed tomography
Short-course preoperative radiotherapy
Selective internal radiation therapy
Capecitabine plus oxaliplatin

Person with suspected colorectal cancer

Person with suspected colorectal cancer

Person with suspected colorectal cancer

NICE has developed a guideline on referral for suspected cancer and a pathway on colonoscopic surveillance for people at risk of developing colorectal cancer.

Emergency presentation

Emergency presentation

Emergency presentation

Initial management of acute large bowel obstruction

Resuscitate patient.
Offer CT of the chest, abdomen and pelvis to confirm the diagnosis of mechanical obstruction, and to determine whether the patient has metastatic disease or colonic perforation.
Do not use contrast enema studies as the only imaging modality in patients presenting with acute large bowel obstruction.

When to consider colonic stents

Consider placing a self-expanding metallic stent to initially manage a left-sided complete or near-complete colonic obstruction.
Do not place self-expanding metallic stents in low rectal lesions, to relieve right-sided colonic obstruction, or if there is clinical or radiological evidence of colonic perforation or peritonitis.
A consultant colorectal surgeon should consider inserting a colonic stent in patients presenting with acute large bowel obstruction. They should do this together with an endoscopist or a radiologist (or both) who is experienced in using colonic stents.
Only a healthcare professional experienced in placing colonic stents who has access to fluoroscopic equipment and trained support staff should insert colonic stents.
Do not dilate the tumour before inserting the stent.
If a self-expanding metallic stent is suitable attempt insertion urgently and no longer than 24 hours after patients present with colonic obstruction.

Source guidance

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Information

Information

Information

Offer verbal and written information in a way that is clearly understood by patients and free from jargon. Include information about support organisations or internet resources recommended by the clinical team.

Before treatment

Before starting treatment, offer information about all available options (including no treatment), and the potential benefits and risks, including the effect on bowel function.

After treatment

After any treatment, offer all patients specific information on managing the effects of the treatment on their bowel function. This could include information on incontinence, diarrhoea, difficulty emptying bowels, bloating, excess flatus and diet, and where to go for help in the event of symptoms.

Colorectal cancer services

NICE has written information for the public explaining its cancer service guidance on colorectal cancer and its cancer service guidance on supportive and palliative care.

Information about stomas

Source guidance

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Ongoing care and support

Ongoing care and support

Ongoing care and support

Offer follow-up to all patients with primary colorectal cancer undergoing treatment with curative intent. Start follow-up at a clinic visit 4–6 weeks after potentially curative treatment.
Offer patients regular surveillance with:
  • a minimum of two CTs of the chest, abdomen, and pelvis in the first 3 years and
  • regular serum carcinoembryonic antigen tests (at least every 6 months in the first 3 years).
Offer a surveillance colonoscopy at 1 year after initial treatment. If this investigation is normal consider further colonoscopic follow-up after 5 years, and thereafter as determined by cancer networks. The timing of surveillance for patients with subsequent adenomas should be determined by the risk status of the adenoma.
NICE has produced a pathway on colonoscopic surveillance for people with inflammatory bowel disease or adenomas.
Start reinvestigation if there is any clinical, radiological or biochemical suspicion of recurrent disease (see investigating and diagnosing colorectal cancer).
Stop regular follow-up:
  • when the patient and the healthcare professional have discussed and agreed that the likely benefits no longer outweigh the risks of further tests or
  • when the patient cannot tolerate further treatments.

Quality standards

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Source guidance

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Paths in this pathway

Pathway created: November 2011 Last updated: March 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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