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: the diagnosis and management of colorectal cancer. NICE clinical guideline 131 (2011)
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. NICE technology appraisal guidance 242 (2012)
Bevacizumab in combination with oxaliplatin and either fluorouracil plus folinic acid or capecitabine for the treatment of metastatic colorectal cancer. NICE technology appraisal guidance 212 (2010)
Cetuximab for the first-line treatment of metastatic colorectal cancer. NICE technology appraisal guidance 176 (2009)
Bevacizumab and cetuximab for the treatment of metastatic colorectal cancer. NICE technology appraisal guidance 118 (2007)
Laparoscopic surgery for colorectal cancer. NICE technology appraisal guidance 105 (2006)
Capecitabine and oxaliplatin in the adjuvant treatment of stage III (Dukes' C) colon cancer. NICE technology appraisal guidance 100 (2006)
The use of capecitabine and tegafur with uracil for metastatic colorectal cancer. NICE technology appraisal guidance 61 (2003)
Microwave ablation for the treatment of liver metastases. NICE interventional procedure guidance 406 (2011)
Selective internal radiation therapy for non-resectable colorectal metastases in the liver. NICE interventional procedure guidance 401 (2011)
Percutaneous radiofrequency ablation for primary or secondary lung cancers. NICE interventional procedure guidance 372 (2010)
Cryotherapy for the treatment of liver metastases. NICE interventional procedure guidance 369 (2010)
Endoscopic submucosal dissection of lower gastrointestinal lesions. NICE interventional procedure guidance 335 (2010)
Cytoreduction surgery followed by hyperthermic intraoperative peritoneal chemotherapy for peritoneal carcinomatosis. NICE interventional procedure guidance 331 (2010)
Radiofrequency ablation for colorectal liver metastases. NICE interventional procedure guidance 327 (2009)
Radiofrequency-assisted liver resection. NICE interventional procedure guidance 211 (2007)
Preoperative high dose rate brachytherapy for rectal cancer. NICE interventional procedure guidance 201 (2006)
Laparoscopic liver resection. NICE interventional procedure guidance 135 (2005)
Computed tomographic colonography (virtual colonoscopy). NICE interventional procedure guidance 129 (2005)

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

Implementation

Learning resources

Learning resources are designed to support people to run workshops and for individual learning. They include clinical case scenarios, presentations for trainers and tests for participants.
Colorectal cancer: case study – implementing early rectal cancer multidisciplinary teams in secondary care
Colorectal cancer: clinical case scenarios for secondary care – mixed chemotherapy options

Slide sets

Slide sets provide a framework for discussion and assist in local dissemination of the guidance. The slides contain the key messages from NICE guidance and can be tailored for local presentations.
Colorectal cancer: slide sets

Pathway information

Updates to this pathway

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.
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.

Information for patients and the public

NICE produces booklets for patients and the public, called 'Understanding NICE guidance'. They summarise, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written a booklet for patients and the public explaining its guidance on each of the following topics.

Information about colorectal cancer

Colorectal cancer

Information about drug treatments

Bevacizumab in combination with oxaliplatin and either fluorouracil plus folinic acid or capecitabine for the treatment of metastatic colorectal cancer
Cetuximab for the first-line treatment of metastatic colorectal cancer
Bevacizumab and cetuximab for the treatment of metastatic colorectal cancer
Capecitabine and oxaliplatin in the adjuvant treatment of stage III (Dukes' C) colon cancer
The use of capecitabine and tegafur with uracil for metastatic colorectal cancer
Cetuximab, bevacizumab and panitumumab for metastatic colorectal cancer after first-line chemotherapy
Information about surgery
Laparoscopic surgery for colorectal cancer
Percutaneous radiofrequency ablation for primary or secondary lung cancers
Cryotherapy for the treatment of liver metastases
Endoscopic submucosal dissection of lower gastrointestinal lesions
Cytoreduction surgery followed by hyperthermic intraoperative peritoneal chemotherapy for peritoneal carcinomatosis
Radiofrequency ablation for colorectal liver metastases
Microwave ablation for the treatment of liver metastases
Radiofrequency-assisted liver resection
Preoperative high dose rate brachytherapy for rectal cancer
Laparoscopic liver resection
Computed tomographic colonography (virtual colonoscopy)
Selective internal radiation therapy for colorectal metastases in the liver

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution – 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 someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on consent from the Welsh Government. If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children.

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.
NICE has written a booklet for patients and the public explaining its guidance on colorectal cancer.

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.
NICE has written a booklet for patients and the public explaining its guidance on colorectal cancer.

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

Information about stomas

See information about stomas.

Source guidance

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Investigating and diagnosing colorectal cancer

View the 'Investigating and diagnosing colorectal cancer' path

Staging colorectal cancer

View the 'Staging colorectal cancer' path

Managing local colorectal tumours

View the 'Managing local colorectal tumours' path

Managing advanced and metastatic colorectal cancer

View the 'Managing advanced and metastatic colorectal cancer' path

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.
NICE has produced cancer service guidance on supportive and palliative care.

Source guidance

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Paths in this pathway

Pathway created: November 2011 Last updated: February 2012

Copyright © 2012 National Institute for Health and Clinical Excellence. All Rights Reserved.

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