Late-Stage Colorectal Cancer

Publication Date: March 9, 2020

Key Points

Key Points

  • Approximately 45% of incident colorectal cancers occurred in less-developed regions around the world, representing 9–10% of cancers in those regions. Fifty-two percent of deaths from colorectal cancer occurred in these “less-developed” regions.
    • Many regions do not have mass or even opportunistic screening, and even within regions with mass screening subpopulations may not have access to screening.
  • In recognition of the resource limitations in these regions and to improve the quality of care where resources are limited, ASCO has established a process for development of resource-stratified guidelines, which includes mixed methods of evidence-based guideline development, adaptation of the clinical practice guidelines of other organizations, and formal expert consensus.

Table 1. Framework of Resource Stratification
Note: Use of maximal-level resources typically depends on the existence and functionality of all lower level resources.

Setting Resource Availability
Basic Core resources or fundamental services that are absolutely necessary for any cancer health care system to function. Basic-level services typically are applied in a single clinical interaction.
Limited Second-tier resources or services that are intended to produce major improvements in outcome such as increased survival and cost-effectiveness and are attainable with limited financial means and modest infrastructure. Limited-level services may involve single or multiple interactions. Universal public health interventions feasible for greater percentage of population than primary target group.
Enhanced Third-tier resources or services that are optional but important. Enhanced-level resources should produce further improvements in outcome and increase the number and quality of options and patient choice.
Maximal May use high-resource settings’ guidelines. High-level/state-of-the art resources or services that may be used/available in some high-resource regions and/or may be recommended by high-resource setting guidelines that do not adapt to resource constraints but that nonetheless should be considered a lower priority than those resources or services listed in the other categories on the basis of extreme cost and/or impracticality for broad use in a resource-limited environment. To be useful, maximal-level resources typically depend on the existence and functionality of all lower level resources. Health budgets still require hard choices, and private insurers or public systems may carefully ration access to the most costly therapies.

Diagnosis

...gnosis...

...Question 1.What are the optimal methods...


Treatment

...atment...

...l Question 2.What are the optimal systemic treatme...


...inical Question 3.What are the optimal treatme...


...cal Question 4.What are the optimal treatme...


...al Question 5.What are selected liver-d...


...ion 6. What is a summary of the optimal treatm...


...n 7.What are the optimal on-treatment...


...ns on Symptom Management (Table 2)...

...Patients with advanced-stage colorectal c...

....2 Patients with clinically unstable disea...

...s with clinically unstable disease due...

...ients with clinically unstable disease...

...h clinically stable disease with ongoing bleed...

...sfusion + surgery of primary tumor (ASCO Reso...

...lti-disciplinary specialized evaluation (...


...le 2. Recommendations on Symptom Managem...


Recommendations on Diagnosis...

Pathology

...nts with advanced-stage colorectal cancerTissue ha...

...based on primary tumor...

...ery required to stabilize patient due...

...ents with clinically stable disease, pal...

...ients with clinically stable disease, no palpab...

Flexible sigmoidoscopy (ASCO Resource Le...

...le sigmoidoscopy or colonoscopy (ASCO Resource...

...0 No primary tissue availableProceed to recommen...

...sis based on metastatic disea...

...ally palpable metastatic siteBiopsy palpable mas...

...astatic disease on staging US or C...

1.13 Patients with mCRC for whom MDT c...

...lecular testi...

...of mCRC based on primary tumor or on me...


...mendations on DiagnosisHaving trouble viewing tab...


...mmendations on Staging (Table...

...atients diagnosed with mCRC...

....15

...al rectal exam (ASCO Resource Levels: Basic, Lim...

...ital rectal exam (ASCO Resource Levels: Enhance...

1.16Chest X-Ray and abdominal ultrasound (US)...

....17Contrast enhanced CT scan chest,...

.../CT in selected cases (such as for when...

Population: Liver-only metastatic disease based o...

....19...

...ontrast-enhanced liver USa (if MDT a...

Liver MRI or contrast-enhanced liv...

Population: Rectal pr...

1.20MRI pelvis rectal cancer protocol (ASCO...

...endoscopic ultrasound (ASCO Resource Levels: Enha...


...able 4. Recommendations on StagingHaving t...


...ne Treatment (Table 5)...

....1 RAS unkno...

...care (ASCO Resource Levels: Basic) (S)7264...

...gent fluoropyrimidine if available, if no...

...herapy (ASCO Resource Levels: Enhan...

...rapy ± anti-VEGF (bevacizumab) (ASCO Resource...

...T and right-sided primary tumor...

...chemotherapy (ASCO Resource Levels: E...

...oublet chemotherapy ± anti-VEGF (bevacizumab) (A...

... RAS WT and left-sided pri...

...hemotherapy (ASCO Resource Levels: E...

...emotherapy ± anti-EGFR (ASCO Resource Levels:...

...let chemotherapy ± anti-VEGF (bevac...

2.4 RAS WT ± BRAF MUT, patients with good...

...t chemotherapy (ASCO Resource Levels:...

...hemotherapy ± anti-VEGF (bevacizu...

...T and preexisting neuropathy, elderly, comorbiditi...

Single agent fluoropyrimidine (ASCO Re...

...ngle agent fluoropyrimidine ± anti-VEGF (bevaci...

...T and preexisting neuropathy, elderly, c...

...RAS WT and very poor performance sta...

....8 Any RAS status and dMMR or MSI-...

2.10 RAS...

...oublet chemotherapy (ASCO Resource Levels: Enhanc...

...motherapy ± anti-VEGF (bevacizumab) (ASCO Resourc...

...and patients with good PS and without major com...

...t chemotherapy (ASCO Resource Levels: Enhanced)...

...ay offer triplet chemotherapy ± anti-VEGF (bevaci...

...RAS MUT and preexisting neuropathy, elderly, c...

...nt fluoropyrimidine (ASCO Resource Levels: Lim...

...agent fluoropyrimidine ± anti-VEGF (bevacizu...

...Patients treated with oxaliplatin-based double...

...ronous metastases, prior oxaliplatin-based chem...

...n-based chemotherapy for early-stage disease (...

...ifying Statement for First-Line im...


...rst-Line TreatmentHaving trouble viewing tabl...


...commendations on Second-Line Systemic Colo...

...pertains to Enhanced and Maximal...

...oxaliplatin in first lineIrinotecan or i...

...eceived irinotecan in first lineOxa...

...bevacizumab in first linePatients may receive alte...

... Received bevacizumab in first line...

...may receive an alternate chemotherapy reg...

...rinotecan-based chemotherapy ± ziv-aflibe...

...ecan-based chemotherapy ± ramuciru...

...rapy + irinotecan-based chemotherapy i...

...GFR therapy alone (if not candidate f...

...WT, received anti-EGFR in first...

...chemotherapy (ASCO Resource Levels: Enhanced) (M)...

...ternative chemotherapy ± anti-VEGF therapy (ASCO...

...00E MUT(see full text guideline: Second-Line Syst...

...or MSI-highImmune checkpoint inhibitors (if not...


...Recommendations on Second-Line Systemic Col...


...on Third-Line and Fourth-Line System...

Note: This table pertains to only Maximal setti...

... RAS wild type, and no prior anti-EGFR...

...AS/BRAFRegorafenibb (if available) OR t...

....3 dMMR/MSI-HImmune checkpoint inhibit...

...The combination of cetuximab with irinoteca...


...commendations on Third-Line and Fourt...


...ons on Liver-Directed Therapies in Patients wi...

...e: This table pertains to only Maximal setti...

...ients with liver metastasesUpfront surge...

... Highly selected patients with liver meta...

...with liver metastasesAblative therapies: ra...

...tings, when patients are deemed to have unresec...

5.4 Patients with liver metastases*Hepatic...

...tients with liver metastases*Transarterial che...

... Patients with liver metastases*Se...

...Recommendations should be implemented...


...Recommendations on Liver-Directed Therap...


...ary Treatment Options for Late-Stage Colorecta...

...ery Approaches for the Primary Tumo...

6.1 mCRC

...obstruction, significant bleeding, perforation or...

OR if obstruction from primary tumor or...

...f high risk of obstruction, significan...

...bstruction from primary tumor or fro...

...f obstruction from primary tumor: stenting...

...herapy of Primary Tumor...

...symptomatic primary rectal tumor,...

...emic Treatmen...

... mCRC...

...dines (ASCO Resource Levels: Limited) (S...

...uoropyrimidines plus oxaliplatin (ASCO R...

...SCO Resource Levels: Enhanced) (S)7264...

...pyrimidines plus oxaliplatin (ASCO Res...

...an (S) + anti-VEGF (ASCO Resource L...

...-EGFR (ASCO Resource Levels: Maximal) (M)7264...

...immune check-point inhibitors (AS...

...hibitors (ASCO Resource Levels: Maximal) (W)7264...

...r Metastatic Disease Post-Systemic Treatment...

...have received systemic treatmentSynchroni...

...temic Treatment After Primary Tumor and Metastase...

...who have received surgery/ablat...

...midines (ASCO Resource Levels: Limited)...

...idines plus oxaliplatin (ASCO Resource Levels:...

...notecan (ASCO Resource Levels: Enhan...

...yrimidines plus oxaliplatin (ASCO Res...


Table 9. Summary Treatment Options f...


...s on Surveillance/Follow-Up (Table 10)...

7.1 Patients with metastatic diseas...

...urce Levels: Basic...

...ion (medical history and physical e...

...ork (complete blood count, metabolic pane...

...urce Levels: Limited...

...ation (medical history and physical exam), e...

...blood work (complete blood count, metabolic panel...

...e Levels: Enhanced/Maximal...

...evaluation (medical history and physical exa...

AND CT scans chest/ abdomen/ pelvis every 2–3...

...nts with metastatic disease post curativ...

...source Levels: Basic...

...ation (medical history and physical exam...

...D chest X-Ray and abdominal ultrasound every 6 mo...

...esource Levels: Limited...

...ical evaluation (medical history and...

...n chest/ abdomen/ pelvis every 6 mont...

...urce Levels: Enhanced, Maximal...

...nical evaluation (medical history and physica...

...hest/ abdomen/ pelvis every 3–6 months for 2...


...0. Recommendations on Surveillance/Follo...