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Colorectal cancer

About

What is covered

This pathway covers the diagnosis and management of colorectal cancer. Colorectal cancer is one of the most common cancers 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.

Updates

Updates to this pathway

23 August 2016
  • Trifluridine–tipiracil for previously treated metastatic colorectal cancer (NICE technology appraisal guidance 405) added to subsequent therapy.
  • Pathway restructured and summarised recommendations replaced with full recommendations.
26 April 2016 Microwave ablation for treating liver metastases (NICE interventional procedure guidance 553) added.
15 December 2015 Link added to the NICE guideline on care of dying adults in the last days of life (NG31).
22 September 2015 Low-energy contact X-ray brachytherapy (the Papillon technique) for early-stage rectal cancer (NICE interventional procedure guidance 532) added.
25 August 2015 Preoperative high dose rate brachytherapy for rectal cancer (NICE interventional procedure guidance 531) added.
24 March 2015 Transanal total mesorectal excision of the rectum (NICE interventional procedure guidance 514) added.
24 February 2015 Regorafenib for metastatic colorectal cancer after treatment for metastatic disease (terminated appraisal) (NICE technology appraisal 334) added.
9 December 2014 Fluorouracil chemotherapy: The My5-FU assay for guiding dose adjustment (NICE diagnostics guidance 16) added.
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) and panitumumab in combination with chemotherapy for the treatment of metastatic colorectal cancer (terminated appraisal) (NICE technology appraisal 240) added.
25 June 2013 SonoVue (sulphur hexafluoride microbubbles) – contrast agent for contrast-enhanced ultrasound imaging of the liver (NICE diagnostics guidance 5) added.
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.
24 August 2012 Colorectal cancer (NICE quality standard 20) added.
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.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on diagnosing and managing colorectal cancer in an interactive flowchart.

What is covered

This pathway covers the diagnosis and management of colorectal cancer. Colorectal cancer is one of the most common cancers 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.

Updates

Updates to this pathway

23 August 2016
  • Trifluridine–tipiracil for previously treated metastatic colorectal cancer (NICE technology appraisal guidance 405) added to subsequent therapy.
  • Pathway restructured and summarised recommendations replaced with full recommendations.
26 April 2016 Microwave ablation for treating liver metastases (NICE interventional procedure guidance 553) added.
15 December 2015 Link added to the NICE guideline on care of dying adults in the last days of life (NG31).
22 September 2015 Low-energy contact X-ray brachytherapy (the Papillon technique) for early-stage rectal cancer (NICE interventional procedure guidance 532) added.
25 August 2015 Preoperative high dose rate brachytherapy for rectal cancer (NICE interventional procedure guidance 531) added.
24 March 2015 Transanal total mesorectal excision of the rectum (NICE interventional procedure guidance 514) added.
24 February 2015 Regorafenib for metastatic colorectal cancer after treatment for metastatic disease (terminated appraisal) (NICE technology appraisal 334) added.
9 December 2014 Fluorouracil chemotherapy: The My5-FU assay for guiding dose adjustment (NICE diagnostics guidance 16) added.
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) and panitumumab in combination with chemotherapy for the treatment of metastatic colorectal cancer (terminated appraisal) (NICE technology appraisal 240) added.
25 June 2013 SonoVue (sulphur hexafluoride microbubbles) – contrast agent for contrast-enhanced ultrasound imaging of the liver (NICE diagnostics guidance 5) added.
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.
24 August 2012 Colorectal cancer (NICE quality standard 20) added.
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.

Sources

NICE guidance and other sources used to create this pathway.
Colorectal cancer: diagnosis and management (2011 updated 2014) NICE guideline CG131
Improving outcomes in colorectal cancers (2004) NICE guideline CSG5
Cetuximab for the first-line treatment of metastatic colorectal cancer (2009) NICE technology appraisal guidance 176
Bevacizumab and cetuximab for the treatment of metastatic colorectal cancer (2007 updated 2012) NICE technology appraisal guidance 118
Laparoscopic surgery for colorectal cancer (2006) NICE technology appraisal guidance 105
Microwave ablation for treating liver metastases (2016) NICE interventional procedure guidance 553
Preoperative high dose rate brachytherapy for rectal cancer (2015) NICE interventional procedure guidance 531
Transanal total mesorectal excision of the rectum (2015) NICE interventional procedure guidance 514
Irreversible electroporation for treating liver metastases (2013) NICE interventional procedure guidance 445
Selective internal radiation therapy for non-resectable colorectal metastases in the liver (2011 updated 2013) NICE interventional procedure guidance 401
Percutaneous radiofrequency ablation for primary or secondary lung cancers (2010) NICE interventional procedure guidance 372
Cryotherapy for the treatment of liver metastases (2010) NICE interventional procedure guidance 369
Endoscopic submucosal dissection of lower gastrointestinal lesions (2010) NICE interventional procedure guidance 335
Radiofrequency ablation for colorectal liver metastases (2009) NICE interventional procedure guidance 327
Radiofrequency-assisted liver resection (2007) NICE interventional procedure guidance 211
Laparoscopic liver resection (2005) NICE interventional procedure guidance 135
Computed tomographic colonography (virtual colonoscopy) (2005) NICE interventional procedure guidance 129
CardioQ-ODM oesophageal doppler monitor (2011) NICE medical technology guidance 3
Colorectal cancer (2012) NICE quality standard 20

Quality standards

Colorectal cancer

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.

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

Effective interventions library

Successful effective interventions library details

Implementation

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

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.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

5-fluorouracil
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
positron emission tomography CT
capecitabine plus oxaliplatin

Paths in this pathway

Pathway created: November 2011 Last updated: August 2016

© NICE 2016

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