Metastatic Colorectal Cancer
- All patients included in the evidence-base for Recommendations 1.1 and 1.2 received anti-vascular endothelial growth factor (VEGF) antibody bevacizumab in addition to doublet or triplet CT backbone.
- Shared decision-making is recommended, including a discussion of the potential for benefit and risk of harm. While survival and recurrence outcomes are improved, grade 3 or greater adverse events are more frequent with triplet CT, compared to doublet CT.
- Anti-EGFR therapy is not recommended as first-line therapy for patients with right-sided RAS wild-type mCRC, and consistent with the qualifying statements to Recommendation 1.1 and 1.2, these patients should be offered CT and anti-VEGF therapy.
- Anti-EGFR therapy is not recommended for patients with RAS-mutant mCRC.
- Anti-EGFR therapy with triplet CT is not recommended.
- Although anti-EGFR therapy is preferred, anti-VEGF therapy remains an active treatment option for patients with left-sided, treatment-naïve RAS wild-type mCRC in the first-line setting.
- Shared decision-making is recommended, including a discussion of potential for benefit and risk of harm.
- In the PRODIGE 7 trial, 15% of patients with isolated colorectal peritoneal metastases experienced no disease progression in the five years following surgery, indicating that CRS may be a curative option for an appropriately selected subgroup of patients.
- This recommendation applies to patients who have been deemed amenable to complete resection of colorectal peritoneal metastases, regardless of previous treatment, and who have no extraperitoneal metastases.
- Complete macroscopic cytoreduction was achieved in 91% of patients in the PRODIGE 7 trial, which is attributed to the majority of patients undergoing CRS at centers with substantial clinical experience. CRS should be considered as a treatment option only within these specialized centers.
- Multidisciplinary team (MDT) management is recommended for patients with mCRC who are considered candidates for CRS. The MDT should include expertise in medical oncology, surgical oncology, radiology, and pathology.
- Shared decision-making should include a discussion of the potential impact on quality of life and rate of adverse events associated with CRS.
- MDT management is required for patients with mCRC who are considered candidates for SBRT or SIRT. The MDT should include expertise in medical oncology, radiation oncology, hepatobiliary surgery, and interventional radiology.
- Perioperative CT may be more likely to be recommended over surgery alone in patients with a greater number of metastases or with larger tumors. Shared decision-making, including discussion of the potential for benefits and risks of harm is recommended.
- The choice of perioperative CT or surgery alone, and coordination of treatment sequencing, should be discussed within a multidisciplinary team that includes expertise in medical oncology and hepatobiliary surgery.
- Perioperative CT is recommended for a total pre- and postoperative duration of 6 months, based on total duration of CT in the European Organisation for Research and Treatment of Cancer (EORTC) 40983 trial.
ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care and that all patients should have the opportunity to participate.
Additional information, which may include data supplements, slide sets, and other clinical tools and resources, is available at www.asco.org/gastrointestinal-cancer-guidelines.
- ASCO: American Society Of Clinical Oncology
- CRS: Cytoreductive Surgery
- CT: Chemotherapy
- EGFR: Epidermal Growth Factor Receptor
- EORTC: European Organisation For Research And Treatment Of Cancer
- FOLFIRI: Folinic Acid (leucovorin), Fluorouracil, Irinotecan
- FOLFOX: Folinic Acid (leucovorin), Fluorouracil, Oxaliplatin
- HIPEC: Hyperthermic Intraperitoneal Chemotherapy
- MDT: Multidisciplinary Team
- MSI-H: Microsatellite Instability-high
- MSS: Microsatellite Stable
- SBRT: Stereotactic Body Radiation Therapy
- SIRT: Selective Internal Radiation Therapy
- VEGF: Vascular Endothelial Growth Factor
- dMMR: Deficient Mismatch Repair
- mCRC: Metastatic Colorectal Cancer
- pMMR: Proficient DNA Mismatch Repair