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Colorectal cancer

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What is covered

This NICE Pathway covers diagnosing and managing colorectal (bowel) cancer.

Updates

Updates to this NICE Pathway

3 March 2020 Selective internal radiation therapy for unresectable colorectal metastases in the liver (NICE interventional procedures guidance 672) added to liver metastases.
28 January 2020 Updated on publication of the update of colorectal cancer (NICE guideline NG151).
9 January 2020 Low-energy contact X-ray brachytherapy (the Papillon technique) for locally advanced rectal cancer (NICE interventional procedures guidance 659) withdrawn to allow for further consultation with stakeholders.
13 August 2019 Low-energy contact X-ray brachytherapy (the Papillon technique) for locally advanced rectal cancer (NICE interventional procedures guidance 659) added.
25 June 2019 Reinforcement of a permanent stoma with a synthetic or biological mesh to prevent a parastomal hernia (NICE interventional procedures guidance 654) added.
6 June 2019 Endocuff Vision for assisting visualisation during colonoscopy (NICE medical technologies guidance 45) added.
25 September 2017 Recommendation amended after a change to the commercial arrangements for NICE's technology appraisal guidance on cetuximab and panitumumab for previously untreated metastatic colorectal cancer. The change does not affect the cost effectiveness of cetuximab.
9 May 2017 Virtual chromoendoscopy to assess colorectal polyps during colonoscopy (NICE diagnostics guidance 28) added to diagnostic investigations.
29 March 2017 Added:
  • cetuximab and panitumumab for previously untreated metastatic colorectal cancer (NICE technology appraisal guidance 439)
  • panitumumab in combination with chemotherapy for the treatment of metastatic colorectal cancer (terminated appraisal) (NICE technology appraisal 240).
21 February 2017 Molecular testing strategies for Lynch syndrome in people with colorectal cancer (NICE diagnostics guidance 27) added to diagnostic investigations.
23 August 2016
  • Trifluridine–tipiracil for previously treated metastatic colorectal cancer (NICE technology appraisal guidance 405) added.
  • Structure revised, and summarised recommendations replaced with full recommendations.
26 April 2016 Microwave ablation for treating liver metastases (NICE interventional procedures guidance 553) added.
22 September 2015 Low-energy contact X-ray brachytherapy (the Papillon technique) for early-stage rectal cancer (NICE interventional procedures guidance 532) added.
25 August 2015 Preoperative high dose rate brachytherapy for rectal cancer (NICE interventional procedures guidance 531) added.
24 March 2015 Transanal total mesorectal excision of the rectum (NICE interventional procedures 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.

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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and managing colorectal (bowel) cancer in an interactive flowchart

What is covered

This NICE Pathway covers diagnosing and managing colorectal (bowel) cancer.

Updates

Updates to this NICE Pathway

3 March 2020 Selective internal radiation therapy for unresectable colorectal metastases in the liver (NICE interventional procedures guidance 672) added to liver metastases.
28 January 2020 Updated on publication of the update of colorectal cancer (NICE guideline NG151).
9 January 2020 Low-energy contact X-ray brachytherapy (the Papillon technique) for locally advanced rectal cancer (NICE interventional procedures guidance 659) withdrawn to allow for further consultation with stakeholders.
13 August 2019 Low-energy contact X-ray brachytherapy (the Papillon technique) for locally advanced rectal cancer (NICE interventional procedures guidance 659) added.
25 June 2019 Reinforcement of a permanent stoma with a synthetic or biological mesh to prevent a parastomal hernia (NICE interventional procedures guidance 654) added.
6 June 2019 Endocuff Vision for assisting visualisation during colonoscopy (NICE medical technologies guidance 45) added.
25 September 2017 Recommendation amended after a change to the commercial arrangements for NICE's technology appraisal guidance on cetuximab and panitumumab for previously untreated metastatic colorectal cancer. The change does not affect the cost effectiveness of cetuximab.
9 May 2017 Virtual chromoendoscopy to assess colorectal polyps during colonoscopy (NICE diagnostics guidance 28) added to diagnostic investigations.
29 March 2017 Added:
  • cetuximab and panitumumab for previously untreated metastatic colorectal cancer (NICE technology appraisal guidance 439)
  • panitumumab in combination with chemotherapy for the treatment of metastatic colorectal cancer (terminated appraisal) (NICE technology appraisal 240).
21 February 2017 Molecular testing strategies for Lynch syndrome in people with colorectal cancer (NICE diagnostics guidance 27) added to diagnostic investigations.
23 August 2016
  • Trifluridine–tipiracil for previously treated metastatic colorectal cancer (NICE technology appraisal guidance 405) added.
  • Structure revised, and summarised recommendations replaced with full recommendations.
26 April 2016 Microwave ablation for treating liver metastases (NICE interventional procedures guidance 553) added.
22 September 2015 Low-energy contact X-ray brachytherapy (the Papillon technique) for early-stage rectal cancer (NICE interventional procedures guidance 532) added.
25 August 2015 Preoperative high dose rate brachytherapy for rectal cancer (NICE interventional procedures guidance 531) added.
24 March 2015 Transanal total mesorectal excision of the rectum (NICE interventional procedures 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 interactive flowchart.
Colorectal cancer (2020) NICE guideline NG151
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 procedures guidance 553
Preoperative high dose rate brachytherapy for rectal cancer (2015) NICE interventional procedures guidance 531
Transanal total mesorectal excision of the rectum (2015) NICE interventional procedures guidance 514
Irreversible electroporation for treating liver metastases (2013) NICE interventional procedures guidance 445
Percutaneous radiofrequency ablation for primary or secondary lung cancers (2010) NICE interventional procedures guidance 372
Cryotherapy for the treatment of liver metastases (2010) NICE interventional procedures guidance 369
Endoscopic submucosal dissection of lower gastrointestinal lesions (2010) NICE interventional procedures guidance 335
Radiofrequency ablation for colorectal liver metastases (2009) NICE interventional procedures guidance 327
Radiofrequency-assisted liver resection (2007) NICE interventional procedures guidance 211
Laparoscopic liver resection (2005) NICE interventional procedures guidance 135
Computed tomographic colonography (virtual colonoscopy) (2005) NICE interventional procedures guidance 129
Endocuff Vision for assisting visualisation during colonoscopy (2019) NICE medical technologies guidance 45
Colorectal cancer (2012 updated 2020) NICE quality standard 20
Endo-SPONGE for colorectal anastomotic leakage (2019) NICE medtech innovation briefing 188
OSNA for colon cancer staging (2016) NICE medtech innovation briefing 77

Quality standards

Quality statements

Colonoscopy

This statement has been removed. For more details see update information in the NICE quality standard.

Staging (colon cancer)

This statement has been removed. For more details see update information in the NICE quality standard.

Staging (rectal cancer)

This statement has been removed. For more details see update information in the NICE quality standard.

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 stage 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 stage of local disease recurrence.
Data source: Local data collection.
Process
Proportion of people with rectal cancer who are offered a preoperative treatment strategy appropriate to their stage of local disease recurrence.
Numerator – the number of people in the denominator who are offered a preoperative treatment strategy appropriate to their stage of local disease recurrence.
Denominator – the number of people with rectal cancer.
Data source: Local data collection.
Outcomes
a) Proportion of people with rectal cancer with local disease recurrence.
Data source: National Bowel Cancer Audit and local data collection.
b) Proportion of people with rectal cancer with circumferential resection margin.
Data source: National Bowel Cancer Audit and local data collection.

What the quality statement means for different audiences

Service providers ensure systems are in place for people with rectal cancer to be offered a preoperative treatment strategy appropriate to their stage of local disease recurrence.
Healthcare professionals offer people with rectal cancer a preoperative treatment strategy appropriate to their stage of local disease recurrence.
Commissioners ensure they commission services that offer people with rectal cancer a preoperative treatment strategy appropriate to their stage 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

Colorectal cancer (2020) NICE guideline NG151, recommendations 1.3.2 and 1.3.3

Stage 1 colorectal cancer treatment

This statement has been removed. For more details see update information in the NICE quality standard.

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 metastatic colorectal cancer in the liver have their scans reviewed by the hepatobiliary multidisciplinary team to decide whether further imaging is needed to confirm suitability for local treatment.

Quality measure

Structure
Evidence of local arrangements to ensure people with metastatic colorectal cancer in the liver have their scans reviewed by the hepatobiliary multidisciplinary team to decide whether further imaging is needed to confirm suitability for local treatment.
Data source: Local data collection.
Process
Proportion of people with 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 local treatment.
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 local treatment.
Denominator – the number of people with metastatic colorectal cancer in the liver.
Data source: Local data collection and the National Bowel Cancer Audit.

What the quality statement means for different audiences

Service providers ensure systems are in place for people with metastatic colorectal cancer in the liver to have their scans reviewed by the hepatobiliary multidisciplinary team to decide whether further imaging is needed to confirm suitability for local treatment.
Healthcare professionals ensure people with metastatic colorectal cancer in the liver have their scans reviewed by the hepatobiliary multidisciplinary team to decide whether further imaging is needed to confirm suitability for local treatment.
Commissioners ensure they commission services for people with metastatic colorectal cancer in the liver to have their scans reviewed by the hepatobiliary multidisciplinary team to decide whether further imaging is needed to confirm suitability local treatment.
People with colorectal cancer that has 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

Colorectal cancer (2020) NICE guideline NG151, recommendations 1.5.5 and 1.5.7

Systemic anticancer therapy

This statement has been removed. For more details see update information in the NICE quality standard.

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.
Data source: Local data collection.
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.
Data source: Local data collection.
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.
Data source: Local data collection.
c) Proportion of people free from disease after colorectal resection who receive a clearance colonoscopy at 1 year and a surveillance colonoscopy at 3 years.
Numerator – the number of people in the denominator who receive a clearance colonoscopy at 1 year and a surveillance colonoscopy at 3 years after colorectal resection.
Denominator: the number of people who are free from disease for 1 year after colorectal resection.

What the quality statement means for different audiences

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

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Evidence supports the case for adopting Endocuff Vision in the NHS because it improves the adenoma detection rate during colonoscopy, particularly for people having a colonoscopy as part of bowel cancer screening.
Endocuff Vision should be considered as an option for people having a colonoscopy as part of bowel cancer screening following a positive stool test. There is limited evidence for the benefits of Endocuff Vision in a non-screening population.
Cost modelling shows that for people having a colonoscopy as part of bowel cancer screening, using Endocuff Vision is cost saving. Savings are related to the adenoma detection rate; for a colonoscopist with a baseline adenoma detection rate of 51%, using Endocuff Vision saves £53 per patient over 10 years compared with standard colonoscopy.

Implications of treatments for early rectal cancer (cT1-T2, cN0, M0)

TAE, including TAMIS and TEMS
Type of procedure
Endoscopic/Surgery
Endoscopic
Surgery
Minimally invasive procedure
Yes
Yes
Possible
Resection of bowel (may have more impact on sexual and bowel function)
No
No
Yes
Stoma needed (a permanent or temporary opening in the abdomen for waste to pass through)
No
No
Possible
General anaesthetic needed (and the possibility of associated complications)
Yes
No, conscious sedation
Yes
Able to do a full thickness excision (better chance of removing cancerous cells and more accurate prediction of lymph node involvement)
Yes
No
Yes
Removal of lymph nodes (more accurate staging of the cancer so better chance of cure)
No
No
Yes
Conversion to more invasive surgery needed if complication
Possible
Possible
Possible
Further surgery needed depending on histology
Possible
Possible
Usually no
Usual hospital stay
1 to 2 days
1 to 2 days
5 to 7 days
External scarring
No
No
Yes
Possible complications include (in alphabetical order):
  • Abdominal pain
  • Bleeding
  • Mild anal incontinence
  • Perirectal abscess/sepsis and stricture (narrowing)
  • Perforation
  • Suture line dehiscence (wound reopening)
  • Urinary retention
  • Abdominal pain
  • Bleeding
  • Bloating
  • Perforation
  • Adhesions
  • Anastomotic leak (leaking of bowel contents into the abdomen)
  • Anastomotic stricture (narrowing at internal operation site)
  • Bleeding
  • Incisional hernia (hernia where the surgical incision was made)
  • Injury to neighbouring structures
  • Pelvic abscess
  • Urinary retention
Some of the potential complications shown in the table were identified from the evidence review, others based on committee's expertise.

Factors to take into account when considering resection of the asymptomatic primary tumour

Advantages
Disadvantages
Resection of the asymptomatic primary tumour
  • Possible improvement in overall survival rate (based on low quality evidence from research)
  • Avoidance of primary tumour-related symptoms, such as obstruction, perforation, bleeding and pain
  • Around 5 in 100 people will have severe postoperative complications (based on moderate quality evidence from research)
  • Systemic therapy still needed, and may be delayed if surgical complications occur
No resection (SACT only)
  • Avoids surgery and the potential for postoperative complications
  • Around 20 in 100 people will develop primary tumour-related symptoms such as obstruction, perforation, bleeding and pain that need surgery (based on low quality evidence from research)
Advantages and disadvantages in this table are based on committee expertise unless otherwise indicated. Quality of evidence (based on GRADE): Moderate: True effect is probably close to the estimated effect. Low: True effect might be markedly different from the estimated effect.
Laparoscopic (including laparoscopically assisted) resection is recommended as an alternative to open resection for individuals with colorectal cancer in whom both laparoscopic and open surgery are considered suitable.
Laparoscopic colorectal surgery should be performed only by surgeons who have completed appropriate training in the technique and who perform this procedure often enough to maintain competence. The exact criteria to be used should be determined by the relevant national professional bodies. Cancer networks and constituent trusts should ensure that any local laparoscopic colorectal surgical practice meets these criteria as part of their clinical governance arrangements.
The decision about which of the procedures (open or laparoscopic) is undertaken should be made after informed discussion between the patient and the surgeon. In particular, they should consider:
  • the suitability of the lesion for laparoscopic resection
  • the risks and benefits of the two procedures
  • the experience of the surgeon in both procedures.
For people who have had potentially curative surgical treatment for non-metastatic colorectal cancer, offer follow-up for detection of local recurrence and distant metastases for the first 3 years. Follow-up should include serum CEA and CT scan of the chest, abdomen and pelvis.
For guidance on managing metastases, see managing metastatic colorectal cancer.
Contrast-enhanced ultrasound with SonoVue is recommended for investigating potential liver metastases in adults:
  • if CT is not clinically appropriate, is not accessible or is not acceptable to the person, and
  • in whom an unenhanced ultrasound scan is unsatisfactory and contrast is needed for further diagnosis.

Tumour, node, metastasis classification

This guidance uses the TNM classification developed by the UICC to describe the stage of the cancer. Please refer to The TNM Classification of Malignant Tumours 8th Edition for further information (Brierley JD, Gospodarowicz MK, Wittekind C, eds. UICC. Oxford: Wiley Blackwell, 2017).
In this guidance early rectal cancer is defined as cT1-2, cN0, M0.
cTNM refers to clinical classification based on evidence acquired before treatment, for example imaging, physical examination and endoscopy.
pTNM refers to pathological classification based on histopathology.

Tumour, node, metastasis classification

This guidance uses the TNM classification developed by the UICC to describe the stage of the cancer. Please refer to The TNM Classification of Malignant Tumours 8th Edition for further information (Brierley JD, Gospodarowicz MK, Wittekind C, eds. UICC. Oxford: Wiley Blackwell, 2017).
In this guidance early rectal cancer is defined as cT1-2, cN0, M0.
cTNM refers to clinical classification based on evidence acquired before treatment, for example imaging, physical examination and endoscopy.
pTNM refers to pathological classification based on histopathology.

Tumour, node, metastasis classification

This guidance uses the TNM classification developed by the UICC to describe the stage of the cancer. Please refer to The TNM Classification of Malignant Tumours 8th Edition for further information (Brierley JD, Gospodarowicz MK, Wittekind C, eds. UICC. Oxford: Wiley Blackwell, 2017).
In this guidance early rectal cancer is defined as cT1-2, cN0, M0.
cTNM refers to clinical classification based on evidence acquired before treatment, for example imaging, physical examination and endoscopy.
pTNM refers to pathological classification based on histopathology.

Tumour, node, metastasis classification

This guidance uses the TNM classification developed by the UICC to describe the stage of the cancer. Please refer to The TNM Classification of Malignant Tumours 8th Edition for further information (Brierley JD, Gospodarowicz MK, Wittekind C, eds. UICC. Oxford: Wiley Blackwell, 2017).
In this guidance early rectal cancer is defined as cT1-2, cN0, M0.
cTNM refers to clinical classification based on evidence acquired before treatment, for example imaging, physical examination and endoscopy.
pTNM refers to pathological classification based on histopathology.

Tumour, node, metastasis classification

This guidance uses the TNM classification developed by the UICC to describe the stage of the cancer. Please refer to The TNM Classification of Malignant Tumours 8th Edition for further information (Brierley JD, Gospodarowicz MK, Wittekind C, eds. UICC. Oxford: Wiley Blackwell, 2017).
In this guidance early rectal cancer is defined as cT1-2, cN0, M0.
cTNM refers to clinical classification based on evidence acquired before treatment, for example imaging, physical examination and endoscopy.
pTNM refers to pathological classification based on histopathology.

Tumour, node, metastasis classification

This guidance uses the TNM classification developed by the UICC to describe the stage of the cancer. Please refer to The TNM Classification of Malignant Tumours 8th Edition for further information (Brierley JD, Gospodarowicz MK, Wittekind C, eds. UICC. Oxford: Wiley Blackwell, 2017).
In this guidance early rectal cancer is defined as cT1-2, cN0, M0.
cTNM refers to clinical classification based on evidence acquired before treatment, for example imaging, physical examination and endoscopy.
pTNM refers to pathological classification based on histopathology.

Tumour, node, metastasis classification

This guidance uses the TNM classification developed by the UICC to describe the stage of the cancer. Please refer to The TNM Classification of Malignant Tumours 8th Edition for further information (Brierley JD, Gospodarowicz MK, Wittekind C, eds. UICC. Oxford: Wiley Blackwell, 2017).
In this guidance early rectal cancer is defined as cT1-2, cN0, M0.
cTNM refers to clinical classification based on evidence acquired before treatment, for example imaging, physical examination and endoscopy.
pTNM refers to pathological classification based on histopathology.

Glossary

5-fluorouracil
(when tumour extends beyond what is achievable to resect by TME and needs more extensive surgery to achieve clear margins)
(capecitabine in combination with oxaliplatin)
carcinoembryonic antigen
(tumour invades submucosa as clinically defined)
(tumour invades muscularis propria as clinically defined)
(less than 1mm invasion to mesorectum)
(1 to 5mm invasion into mesorectum)
epidermal growth factor receptor
enhanced recovery after surgery
endoscopic submucosal dissection
(5‑fluorouracil, folinic acid and irinotecan)
(oxaliplatin in combination with 5-fluorouracil and folinic acid)
hyperthermic intraperitoneal chemotherapy
Kirsten rat sarcoma
low anterior resection syndrome
(surgical operations when part or all of the rectum is removed, including anterior resection and abdominoperineal resection)
Multidisciplinary team
positron emission tomography CT
(perioperative care pathways designed to promote early recovery for patients undergoing major surgery by optimising the person's health before surgery and maintaining health and functioning after surgery)
systemic anti-cancer therapy
stereotactic body radiation therapy
selective internal radiation therapy
(this is about changes to people's concept of themselves as a result of either their cancer, or the long-term side effects from treatment, for example, it could cover changes from being a previously fit person to someone who has physical or mental health problems, from being someone with the expectation of years to live to someone with a limited life expectancy, or the change from being a carer to becoming cared for)
transanal excision
transanal minimally invasive surgery
transanal endoscopic microsurgery
total mesorectal excision
tumour, node, metastasis
Union for Interventional Cancer Control
(capecitabine plus oxaliplatin)

Paths in this pathway

Pathway created: November 2011 Last updated: September 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

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