Late-Stage Colorectal Cancer
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
...Diagnosis...
Clinical Question 1.What are the optimal methods...
Treatment
...Treatment...
...tion 2.What are the optimal systemic treatm...
...cal Question 3.What are the optimal tre...
...l Question 4.What are the optimal treatme...
...inical Question 5.What are selected liver-directed...
...nical Question 6. What is a summa...
...estion 7.What are the optimal on-treatme...
...Recommendations on Symp...
...nts with advanced-stage colorectal c...
...atients with clinically unstable di...
....3 Patients with clinically unstable disease...
...4 Patients with clinically unstab...
...th clinically stable disease with ongoin...
...ansfusion + surgery of primary tumor (AS...
...+ multi-disciplinary specialized evaluation (ASCO...
...endations on Symptom Management...
...Recommendations on...
...tients with advanced-stage colorectal cancerTiss...
...Diagnosis ba...
...y required to stabilize patient due to obstru...
... Patients with clinically stable dise...
...ients with clinically stable disease,...
...sigmoidoscopy (ASCO Resource Levels...
...xible sigmoidoscopy or colonoscopy (ASC...
...0 No primary tissue availableProceed to recommend...
...Diagnosis based o...
...y palpable metastatic siteBiopsy palpab...
...disease on staging US or Chest X...
... Patients with mCRC for whom MDT co...
...Molec...
...nosis of mCRC based on primary tumor or on met...
...ommendations on Diagnosis...
...Recommendations...
...Population...
1.1...
...gital rectal exam (ASCO Resource Levels: B...
...l exam (ASCO Resource Levels: Enhan...
...and abdominal ultrasound (US) (ASCO...
...enhanced CT scan chest, abdomen, pelv...
...in selected cases (such as for when MDT is di...
...Population:...
1.19
...ver MRI or contrast-enhanced liver...
...MRI or contrast-enhanced liver USa (ASCO Resource...
...Population: Rect...
...vis rectal cancer protocol (ASCO Resource...
...oscopic ultrasound (ASCO Resource Levels: Enhan...
.... Recommendations on Staging Po...
...First-Line Treatment (...
... RAS unknown...
...re (ASCO Resource Levels: Basic) (S)7264...
...ngle agent fluoropyrimidine if available, if...
...et chemotherapy (ASCO Resource Levels: Enhan...
...ublet chemotherapy ± anti-VEGF (bevaci...
...T and right-sided primary tumor
...rapy (ASCO Resource Levels: Enhanced) (S...
...ublet chemotherapy ± anti-VEGF (bevacizumab) (...
....3 RAS WT and left-sided pri...
...et chemotherapy (ASCO Resource Levels: Enhanced) (...
...chemotherapy ± anti-EGFR (ASCO Resource...
...blet chemotherapy ± anti-VEGF (be...
...T ± BRAF MUT, patients with good P...
...et chemotherapy (ASCO Resource Levels:...
...emotherapy ± anti-VEGF (bevacizumab) (A...
....5 RAS WT and preexisting neuropathy,...
...agent fluoropyrimidine (ASCO Resource Le...
...fluoropyrimidine ± anti-VEGF (bevacizu...
...S WT and preexisting neuropathy, elderly, comorbid...
...and very poor performance status (PS 3–4) o...
... Any RAS status and dMMR or MSI-H and pat...
...0 RAS MU...
...let chemotherapy (ASCO Resource Levels: Enhanced)...
...erapy ± anti-VEGF (bevacizumab) (...
...d patients with good PS and without major comorbi...
...ffer triplet chemotherapy (ASCO Resource Level...
...triplet chemotherapy ± anti-VEGF (beva...
...and preexisting neuropathy, elderl...
...uoropyrimidine (ASCO Resource Levels: Li...
...nt fluoropyrimidine ± anti-VEGF (bevacizumab) (...
...b Patients treated with oxaliplatin-based doub...
...etachronous metastases, prior oxaliplatin-based ch...
...tin-based chemotherapy for early-stage disease (...
...ng Statement for First-Line immunothe...
...5. First-Line Treatment...
...Recommendations...
...is table pertains to Enhanced and Maximal...
...ved oxaliplatin in first lineIrinote...
...eived irinotecan in first lineOxaliplatin-ba...
....3 No bevacizumab in first linePatients may recei...
...bevacizumab in first line...
...may receive an alternate chemothe...
...otecan-based chemotherapy ± ziv-aflibercept...
...sed chemotherapy ± ramucirumab (wh...
...anti-EGFR therapy + irinotecan-based chemothe...
...rapy alone (if not candidate for irinotecan) (...
...WT, received anti-EGFR in first...
...tive chemotherapy (ASCO Resource Levels: E...
...ive chemotherapy ± anti-VEGF therapy (ASCO Resour...
... BRAF V600E MUT(see full text guideline: Second...
...dMMR or MSI-highImmune checkpoint inhibi...
Table 6. Recommendations on Second-Line Sy...
...Recommendatio...
...pertains to only Maximal settings...
...pe, and no prior anti-EGFR therapyAnti-EGFR...
.../BRAFRegorafenibb (if available) OR tri...
...SI-HImmune checkpoint inhibitors (if...
...ombination of cetuximab with irinote...
...Recommendations on Third-Line and Fourth...
...Recommen...
...table pertains to only Maximal settings
...ts with liver metastasesUpfront surgery of metast...
...selected patients with liver metastasesCombination...
...s with liver metastasesAblative therapies: radiof...
...n Maximal Settings, when patients...
...Patients with liver metastases*Hepatic art...
....5 Patients with liver metastases...
...nts with liver metastases*Selective internal...
* NOTE: Recommendations should be imp...
...Recommendations on Liver-Directed Therap...
...Summary Treatmen...
...Surge...
6.1 mC...
...h risk of obstruction, significant bleeding, per...
...tion from primary tumor or from pe...
...of obstruction, significant bleedi...
...tion from primary tumor or from peritoneal...
...truction from primary tumor: stenting (ASCO Resou...
...Radiation Ther...
...mRectalIf symptomatic primary rectal tumor, rad...
...Systemic Treatment...
... mCRC...
Fluoropyrimidines (ASCO Resource Le...
...es plus oxaliplatin (ASCO Resource L...
...(ASCO Resource Levels: Enhanced) (S)7...
...es plus oxaliplatin (ASCO Resource Levels: Maxi...
...n (S) + anti-VEGF (ASCO Resource Levels: Maxim...
...R (ASCO Resource Levels: Maximal) (M)7264...
...check-point inhibitors (ASCO Resource Levels...
...ors (ASCO Resource Levels: Maximal) (W...
...Surgery for Metastatic...
...C who have received systemic treatmentSy...
...Systemic...
...who have received surgery/ablation...
...ropyrimidines (ASCO Resource Levels: Limited)...
...midines plus oxaliplatin (ASCO Resource Levels: E...
...can (ASCO Resource Levels: Enhanced) (S)726...
...es plus oxaliplatin (ASCO Resource Leve...
...ary Treatment Options for Late-Stage Colore...
...Recommendations on...
...7.1 Patients with meta...
...esource Levels: Basic...
...l evaluation (medical history and physical exa...
...(complete blood count, metabolic pan...
...SCO Resource Levels: Li...
...aluation (medical history and physical exa...
...d work (complete blood count, metabolic panel...
...Resource Levels: Enhanced/Maximal...
...valuation (medical history and physical exam)...
...CT scans chest/ abdomen/ pelvis every 2...
...7.2 Patients wit...
...urce Levels: Basic...
...uation (medical history and physical exam) (S)726...
...X-Ray and abdominal ultrasound every 6 months...
ASCO Resource Levels: Limite...
...cal evaluation (medical history and physical exam...
...scan chest/ abdomen/ pelvis every 6 months f...
...esource Levels: Enhanced, Maxim...
Clinical evaluation (medical history and p...
...st/ abdomen/ pelvis every 3–6 months for 2 year...
...ecommendations on Surveillance/Follow-Up...