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
...iagnos...
...al Question 1.What are the optimal methods of i...
Treatment
...atment...
...n 2.What are the optimal systemic treatments for p...
...estion 3.What are the optimal treatme...
Clinical Question 4.What are the o...
...uestion 5.What are selected liver-d...
...uestion 6. What is a summary of the optimal tr...
...ical Question 7.What are the optimal...
...dations on Symptom Management (Table 2)
...ith advanced-stage colorectal cancerCli...
...Patients with clinically unstable disease due t...
...tients with clinically unstable dise...
...Patients with clinically unstable dis...
...h clinically stable disease with ongoi...
...urgery of primary tumor (ASCO Resourc...
...ransfusion + multi-disciplinary specialized evalu...
Table 2. Recommendations on Symptom Manag...
...ndations on Diagnosis (Table 3)...
...thology...
1.6 Patients with advanced-stage...
...based on primary tumor...
...7 Surgery required to stabilize patient d...
...ents with clinically stable disease, palpable mas...
...ts with clinically stable disease,...
...sigmoidoscopy (ASCO Resource Levels: Limited)...
...sigmoidoscopy or colonoscopy (ASCO Resource...
...0 No primary tissue availableProceed to r...
...is based on metastatic disea...
...inically palpable metastatic siteBiops...
...tic disease on staging US or Chest X Ray or CT s...
... Patients with mCRC for whom MDT consid...
...cular testing...
... Diagnosis of mCRC based on primary tum...
...Recommendations on DiagnosisHaving...
...endations on Staging (Table 4)...
...tion: Patients diagnosed with mC...
1.1...
...ital rectal exam (ASCO Resource Levels: Basic,...
...al rectal exam (ASCO Resource Levels: Enhanced...
1.16Chest X-Ray and abdominal ultrasou...
...anced CT scan chest, abdomen, pelvis (ASCO Resour...
...CT in selected cases (such as for when MDT i...
...n: Liver-only metastatic disease based on imaging...
1.1...
...trast-enhanced liver USa (if MDT availa...
...or contrast-enhanced liver USa (ASC...
...lation: Rectal prima...
...0MRI pelvis rectal cancer protocol (...
...ctal endoscopic ultrasound (ASCO Resource Levels...
...endations on StagingHaving trouble...
...rst-Line Treatment (Ta...
....1 RAS unkno...
...are (ASCO Resource Levels: Basic)...
...t fluoropyrimidine if available, if no...
...let chemotherapy (ASCO Resource Levels: Enhanced)...
...chemotherapy ± anti-VEGF (bevacizumab) (A...
... RAS WT and right-sided prima...
...ublet chemotherapy (ASCO Resource Levels: En...
...blet chemotherapy ± anti-VEGF (bevaci...
...3 RAS WT and left-sided primary tum...
...hemotherapy (ASCO Resource Levels: Enhanced...
Doublet chemotherapy ± anti-EGFR (...
...oublet chemotherapy ± anti-VEGF (bevacizumab...
...4 RAS WT ± BRAF MUT, patients with...
...et chemotherapy (ASCO Resource Levels:...
...emotherapy ± anti-VEGF (bevacizumab) (ASCO Res...
...preexisting neuropathy, elderly, comorbidities, or...
...ent fluoropyrimidine (ASCO Resource Levels: Li...
...fluoropyrimidine ± anti-VEGF (bevacizumab) (...
...S WT and preexisting neuropathy, elderl...
2.7 RAS WT and very poor performance status (PS...
...Any RAS status and dMMR or MSI-H and...
...0 RAS MUT...
...erapy (ASCO Resource Levels: Enhanced) (S)7264...
...therapy ± anti-VEGF (bevacizumab) (ASCO R...
...MUT and patients with good PS and wi...
...triplet chemotherapy (ASCO Resource Levels: Enhan...
...offer triplet chemotherapy ± anti-VEGF (bevaciz...
...2 RAS MUT and preexisting neuropath...
...uoropyrimidine (ASCO Resource Leve...
Single agent fluoropyrimidine ± anti-VEGF (...
...Patients treated with oxaliplatin-b...
...tachronous metastases, prior oxaliplatin-base...
...r oxaliplatin-based chemotherapy for e...
...Qualifying Statement for First-Line immunoth...
...st-Line TreatmentHaving trouble viewing table...
...ecommendations on Second-Line Systemic Colorecta...
...pertains to Enhanced and Maximal settings, w...
...xaliplatin in first lineIrinotecan o...
...irinotecan in first lineOxaliplatin-based doublet...
...umab in first linePatients may receive alternat...
...ceived bevacizumab in first line...
...ceive an alternate chemotherapy regimen ± bev...
...irinotecan-based chemotherapy ± ziv-aflibercep...
...R irinotecan-based chemotherapy ±...
...anti-EGFR therapy + irinotecan-based c...
...erapy alone (if not candidate for irinotecan) (AS...
...S WT, received anti-EGFR in fir...
...otherapy (ASCO Resource Levels: En...
...e chemotherapy ± anti-VEGF therapy (ASCO Reso...
...00E MUT(see full text guideline: Second-L...
...MR or MSI-highImmune checkpoint inhibitors (...
...mmendations on Second-Line Systemic Colorect...
...ndations on Third-Line and Fourth-Line...
...able pertains to only Maximal settin...
...ld type, and no prior anti-EGFR therapyAnt...
...FRegorafenibb (if available) OR triflur...
...I-HImmune checkpoint inhibitors (if no...
a The combination of cetuximab with irinote...
...commendations on Third-Line and Fourth...
...ns on Liver-Directed Therapies in Pa...
...te: This table pertains to only Maximal settings
...with liver metastasesUpfront surgery of metasta...
...cted patients with liver metastasesCombinati...
...ith liver metastasesAblative therapies: radi...
...ttings, when patients are deemed t...
...ts with liver metastases*Hepatic arterial infusion...
... Patients with liver metastases*Tran...
...Patients with liver metastases*Sel...
* NOTE: Recommendations should be imple...
Table 8. Recommendations on Liver-Dire...
...y Treatment Options for Late-Stage C...
...rgery Approaches for the Primary Tumor
...1 mCRC...
...sk of obstruction, significant bleeding, perfora...
...struction from primary tumor or from per...
...gh risk of obstruction, significant bleedin...
...f obstruction from primary tumor or from perit...
...ction from primary tumor: stenting (...
...herapy of Primary Tumor...
...ectalIf symptomatic primary rectal tumo...
...mic Treatment...
... mCRC...
...dines (ASCO Resource Levels: Limited)...
...ropyrimidines plus oxaliplatin (ASC...
...tecan (ASCO Resource Levels: Enhanced) (S)7264...
...luoropyrimidines plus oxaliplatin (ASC...
...rinotecan (S) + anti-VEGF (ASCO Reso...
...GFR (ASCO Resource Levels: Maximal) (M)7264...
...mune check-point inhibitors (ASCO Reso...
...AF inhibitors (ASCO Resource Levels: M...
...rgery for Metastatic Disease Post-Syst...
....4 mCRC who have received systemic treatmentSynch...
...temic Treatment After Primary Tumor and...
...who have received surgery/ablat...
...midines (ASCO Resource Levels: Limited)...
...s plus oxaliplatin (ASCO Resource Levels...
...rinotecan (ASCO Resource Levels: Enhanced) (...
...nes plus oxaliplatin (ASCO Resource...
...le 9. Summary Treatment Options for Late...
...ations on Surveillance/Follow-Up (...
7.1 Patients with metastatic disease on acti...
...source Levels: Basic...
...ation (medical history and physical...
...od work (complete blood count, metabolic panel in...
...Resource Levels: Limited...
...cal evaluation (medical history and...
...blood work (complete blood count, me...
ASCO Resource Levels: Enhan...
...ion (medical history and physical exa...
...scans chest/ abdomen/ pelvis every 2–3 months...
... Patients with metastatic disease post curative-i...
...CO Resource Levels:...
...uation (medical history and physical exam) (S)...
...X-Ray and abdominal ultrasound every...
ASCO Resource Levels: Limited
...tion (medical history and physical...
...chest/ abdomen/ pelvis every 6 months for 2 yea...
...esource Levels: Enhanced, Maximal...
...luation (medical history and physic...
...cans chest/ abdomen/ pelvis every 3–6...
.... Recommendations on Surveillance/Follow-...