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
...gnosis...
...Question 1.What are the optimal methods...
Treatment
...reatmen...
...linical Question 2.What are the opt...
...stion 3.What are the optimal treatmen...
...nical Question 4.What are the optimal treatmen...
...Question 5.What are selected liver-d...
...ical Question 6. What is a summary of...
...l Question 7.What are the optimal on-tr...
...mmendations on Symptom Managemen...
...with advanced-stage colorectal cancerCli...
...nts with clinically unstable disease...
...ents with clinically unstable disease due to bow...
...atients with clinically unstable disea...
1.5 Patients with clinically stable...
...usion + surgery of primary tumor (ASCO Resource...
...ulti-disciplinary specialized evalua...
...Recommendations on Symptom Manageme...
...endations on Diagnosis (Ta...
Pathology
...s with advanced-stage colorectal cancerT...
...sis based on primary t...
... Surgery required to stabilize patient du...
...ts with clinically stable disease,...
...ents with clinically stable disease, no palpab...
...ble sigmoidoscopy (ASCO Resource Levels:...
...oidoscopy or colonoscopy (ASCO Resource...
...primary tissue availableProceed to recomme...
...iagnosis based on metastatic disease
1.11 Clinically palpable metastati...
...tic disease on staging US or Chest X Ray o...
...3 Patients with mCRC for whom MDT c...
...cular testing...
...14 Diagnosis of mCRC based on primary tumo...
...endations on Staging...
...atients diagnosed with mCRC...
1.1...
...l exam (ASCO Resource Levels: Basic,...
...exam (ASCO Resource Levels: Enhanced, Maximal) (W...
...t X-Ray and abdominal ultrasound (U...
...nhanced CT scan chest, abdomen, pelvis (A...
...CT in selected cases (such as for when...
...pulation: Liver-only metastatic disease based...
....19
Liver MRI or contrast-enhanced liver US...
...or contrast-enhanced liver USa (ASCO Resou...
...pulation: Rectal primar...
...elvis rectal cancer protocol (ASCO Resourc...
...tal endoscopic ultrasound (ASCO Reso...
First-Line Treatme...
...1 RAS unkno...
...ative care (ASCO Resource Levels: Basic...
...t fluoropyrimidine if available, if not, ref...
...et chemotherapy (ASCO Resource Levels: Enhance...
...oublet chemotherapy ± anti-VEGF (bevacizumab...
...S WT and right-sided primary tu...
...let chemotherapy (ASCO Resource Le...
...blet chemotherapy ± anti-VEGF (bevacizumab)...
...nd left-sided primary tumor...
...emotherapy (ASCO Resource Levels: E...
...therapy ± anti-EGFR (ASCO Resource Levels:...
...ublet chemotherapy ± anti-VEGF (bevacizuma...
...BRAF MUT, patients with good PS and without major...
...riplet chemotherapy (ASCO Resource Levels: Enh...
...et chemotherapy ± anti-VEGF (bevacizum...
...RAS WT and preexisting neuropathy, e...
...t fluoropyrimidine (ASCO Resource L...
...gle agent fluoropyrimidine ± anti-VEGF (bev...
...WT and preexisting neuropathy, elderly, comorb...
... RAS WT and very poor performance...
... Any RAS status and dMMR or MSI-H and patient...
....10 RAS...
...erapy (ASCO Resource Levels: Enhanced) (S)7...
...ublet chemotherapy ± anti-VEGF (bevacizumab) (ASC...
...1 RAS MUT and patients with good PS and wit...
...offer triplet chemotherapy (ASCO Resou...
...riplet chemotherapy ± anti-VEGF (bevacizuma...
....12 RAS MUT and preexisting neurop...
...agent fluoropyrimidine (ASCO Resource Leve...
...gle agent fluoropyrimidine ± anti-VEG...
2.13b Patients treated with oxalipla...
... Metachronous metastases, prior oxalipla...
...iplatin-based chemotherapy for early-stage dise...
...mendations on Second-Line Systemic C...
...se recommendations pertain to Enhanced and Max...
...ved oxaliplatin in first lineIrinotecan or ir...
...Received irinotecan in first lineOxaliplatin-b...
...acizumab in first linePatients may...
...ed bevacizumab in first line...
...may receive an alternate chemotherapy regime...
...ecan-based chemotherapy ± ziv-aflibercept (whe...
...R irinotecan-based chemotherapy ± ramuciruma...
...therapy + irinotecan-based chemotherap...
...apy alone (if not candidate for irinotecan) (ASCO...
...eceived anti-EGFR in first line...
...ve chemotherapy (ASCO Resource Level...
...hemotherapy ± anti-VEGF therapy (ASCO Resour...
...E MUT(see full text guideline: Second-Line...
...SI-highImmune checkpoint inhibitors...
...commendations on Third-Line and Fourth-Line Sy...
...These recommendations pertain to only...
....1 RAS wild type, and no prior anti-EGFR therap...
...BRAFRegorafenibb (if available) OR t...
...mmune checkpoint inhibitors (if no...
Recommendations on Liver-Directed Therapies i...
...hese recommendations pertain to only Maxi...
...Patients with liver metastasesUpfront surgery of...
...2 Highly selected patients with liver metastase...
...with liver metastasesAblative therapies: rad...
...ettings, when patients are deemed to have...
...ts with liver metastases*Hepatic arterial i...
...Patients with liver metastases*Transa...
...nts with liver metastases*Selective in...
...E: Recommendations should be implemen...
Summary Treatment Options for Late-Stage Colo...
...urgery Approaches for the Primary...
...1 mCRC
...risk of obstruction, significant bleeding, perfo...
...R if obstruction from primary tumor or from...
If high risk of obstruction, signific...
...f obstruction from primary tumor or from...
...on from primary tumor: stenting (ASCO Resour...
Radiation Therapy of Primary...
... mRectalIf symptomatic primary rectal tum...
...ystemic Treatment...
6.3 mCRC
...idines (ASCO Resource Levels: Limited...
...uoropyrimidines plus oxaliplatin (ASCO Re...
...irinotecan (ASCO Resource Levels: Enh...
...ropyrimidines plus oxaliplatin (ASCO Resource Le...
...notecan (S) + anti-VEGF (ASCO Resourc...
...EGFR (ASCO Resource Levels: Maximal) (M)726...
...mune check-point inhibitors (ASCO Resource Le...
...nhibitors (ASCO Resource Levels: Maximal) (W)7264...
...for Metastatic Disease Post-Systemic Tre...
...4 mCRC who have received systemic treatmentS...
...emic Treatment After Primary Tumor...
...mCRC who have received surgery/ablati...
...imidines (ASCO Resource Levels: Limited) (S)7264...
...nes plus oxaliplatin (ASCO Resource Levels:...
...otecan (ASCO Resource Levels: Enhanced)...
...s plus oxaliplatin (ASCO Resource L...
...dations on Surveillance/Follow-U...
...s with metastatic disease on active treatment or...
...ource Levels: Basic...
...ation (medical history and physical exam), ever...
...blood work (complete blood count, metabolic...
...Resource Levels: Limi...
...uation (medical history and physical...
...od work (complete blood count, metabolic pan...
...O Resource Levels: Enhanced/Maximal...
...uation (medical history and physical...
...CT scans chest/ abdomen/ pelvis every 2–...
...ients with metastatic disease post curative-inten...
...ource Levels: Basi...
...valuation (medical history and physica...
...chest X-Ray and abdominal ultrasound every 6 month...
...ource Levels: Limited...
...ation (medical history and physical exam), CEA, e...
...chest/ abdomen/ pelvis every 6 months f...
...e Levels: Enhanced, Maximal...
...al evaluation (medical history and physic...
...est/ abdomen/ pelvis every 3–6 months for...