Last updated March 14, 2022

Management of Colon Cancer

Summary of Recommendations

What Is New in the 2021 ASCRS Colon Cancer Clinical Practice Guidelines

2021 New Recommendations
Neoadjuvant therapy #6. When neoadjuvant therapy is not included in the treatment plan, curative intent colectomy should be performed without unneeded delay. Grade of recommendation: strong recommendation based on low quality evidence, 1C.
Neoadjuvant therapy #12. In patients with locally advanced colon cancer, neoadjuvant chemotherapy or radiotherapy can result in tumor regression and may facilitate margin-negative excision of locally advanced cancers. Grade of recommendation: weak recommendations based on moderate-quality evidence, 2B
Multidisciplinary discussion #21. The treatment of patients with resectable stage IV colon cancer should be individualized and based on a comprehensive multidisciplinary discussion. Grade of recommendation: strong recommendation based on moderate quality evidence, 1B.
Resectable liver metastasis #22. Patients with initially resectable colon cancer liver metastasis, an individualized decision on neoadjuvant chemotherapy followed by surgical resection or up-front surgery. Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B.
Unresectable liver metastasis #23. Patients with initially unresectable colon cancer liver metastasis should be considered for neoadjuvant chemotherapy to attempt to convert to resectability. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B.
Hepatic artery infusion of chemotherapy #24. Hepatic artery infusion of chemotherapy combined with systemic chemotherapy or immunotherapy may increase resectability of colon cancer liver metastasis, but should only be performed in centers with the appropriate expertise. Strong recommendation based on moderate-quality evidence, 1B.
Combined or staged liver resection #25. In patients with colon cancer and resectable liver metastasis, a single “combined” operation is generally recommended for relatively low complexity operations and sequential or “staged” operations are generally recommended for higher complexity cases. Grade of recommendation: weak recommendation based on moderate quality evidence, 2B.
Lung metastasis #26. In patients with resectable colon cancer lung metastasis, resection of the lung lesions should be considered as it may prolong survival. Weak recommendation based on moderate-quality evidence, 2B.
Mismatch repair #32. In patients with stage IV (dMMR or MSI-H colon cancer, immunotherapy with antibody to PD-L1 or PD-1 should be considered. Strong recommendation based on high quality evidence, 1A
Timing of adjuvant chemotherapy #33. In general, and if possible, adjuvant chemotherapy should be started within 8 weeks of colon resection. Grade of recommendation: strong recommendation based on moderate quality evidence, 1B
Multigene assays #34. The use of multigene assays, CDX2 expression analysis, and ctDNA may be used to complement multidisciplinary decision-making for patients with stage II or III colon cancer. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B.
2021 Updated Recommendations
PET/CT #4. PET/CT is generally not recommended for routine colon cancer staging but may be useful in surgical decision-making for patients with stage IV disease. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B.
T4b cancers #10. For resectable colon cancers that adhere to or invade adjacent organs and are being treated with curative intent, complete and en bloc resection with negative margins is recommended. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B.
Oophorectomy #11. Oophorectomy is typically advised for grossly abnormal ovaries or contiguous extension of colon cancer, but routine prophylactic oophorectomy is not recommended. Grade of recommendation: strong recommendation based on low-quality evidence, 1C.
Malignant polyp #15. For patients with a “malignant polyp,” either endoscopic excision or oncological resection may be appropriate, and is dependent largely on polyp histopathological features and completeness of excision. Grade of recommendation: strong recommendation based on moderate quality evidence, 1B.
Obstructing left-side colon cancer #17. For patients with obstructing left-sided colon cancer and curable disease, endoscopic stent decompression, or diverting colostomy, with interval colectomy, are generally preferable to emergent colectomy. Grade of recommendation: strong recommendation based on moderate quality evidence, 1B.
Cancer perforation #18. In the setting of perforation or impending perforation of the colon, resection following established oncological principles with a low threshold for performing a staged procedure is recommended when feasible. Grade of recommendation: strong recommendation based on low-quality evidence, 1C.
Cytoreductive surgery #27. In patients with resectable colorectal cancer peritoneal metastases, cytoreductive surgery with or without intraperitoneal chemotherapy should be considered as part of a multimodality treatment plan. Strong recommendation based on moderate quality evidence, 1B.
Stage IV with asymptomatic primary tumor #28. In patients with incurable stage IV colon cancer and an asymptomatic primary colon cancer, systemic chemotherapy is recommended as the initial treatment. Grade of recommendation: strong recommendation based on moderate quality evidence, 1B.
Obstructing colon cancer in palliative setting #29. In patients with an obstructing colon cancer and incurable metastatic disease, or in other scenarios in which palliation is preferred over an attempt at cure, endoscopic stent placement or fecal diversion is preferable to colectomy when life expectancy is <1 year. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
Stage II and adjuvant chemotherapy #30. In patients with microsatellite stable/mismatch repair proficient stage II colon cancer and obstruction, or perforation, or <12 lymph nodes in the resection specimen, or poor differentiation, or lymphovascular invasion, or perineural invasion, or high-level tumor budding, adjuvant chemotherapy may offer a survival benefit. Weak recommendation based on moderate quality evidence, 2B
2017 Recommendations Excluded
Sentinel lymph nodes SLN mapping for colon cancer does not replace standard lymphadenectomy. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B. A recommendation on this technique was excluded as its use has not been broadly adopted for clinical practice.
Minimally invasive surgery Hand-assisted laparoscopic and robotic surgical techniques for right colon cancer result in oncological outcomes that are equivalent to open or straight laparoscopic techniques. Strong recommendation based on moderate-quality evidence, 1B. In 2021, hand-assisted laparoscopic and robotic colectomy techniques were included in recommendation #13: When expertise is available, a minimally invasive approach to elective colectomy for colon cancer is preferred. Grade of recommendation: strong recommendation based on high-quality evidence, 1A.

Recommendation Grading

Overview

Title

Management of Colon Cancer

Authoring Organization

Publication Month/Year

January 18, 2022

Document Type

Guideline

Country of Publication

US

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Scope

Management

Diseases/Conditions (MeSH)

D003110 - Colonic Neoplasms

Keywords

colon cancer, CRC

Source Citation

Vogel JD, Felder SI, Bhama AR, Hawkins AT, Langenfeld SJ, Shaffer VO, Thorsen AJ, Weiser MR, Chang GJ, Lightner AL, Feingold DL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colon Cancer. Dis Colon Rectum. 2022 Feb 1;65(2):148-177. doi: 10.1097/DCR.0000000000002323. PMID: 34775402.

Methodology

Number of Source Documents
328
Literature Search Start Date
January 1, 2009
Literature Search End Date
December 2, 2020