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

...iagnosis...

...on 1.What are the optimal methods of initial sympt...


Treatment

...eatment...

...al Question 2.What are the optimal systemi...


...stion 3.What are the optimal treatme...


...ical Question 4.What are the optimal treatments f...


...ical Question 5.What are selected...


...estion 6. What is a summary of the optimal t...


...nical Question 7.What are the opti...


Recommendations on Symptom Management (Tabl...

...with advanced-stage colorectal ca...

...tients with clinically unstable dis...

...ts with clinically unstable disease due to...

...ients with clinically unstable disease due to bow...

....5 Patients with clinically stable disea...

...n + surgery of primary tumor (ASCO Resourc...

...nsfusion + multi-disciplinary specialized evaluati...


...ecommendations on Symptom ManagementHaving trouble...


...endations on Diagnosis (Table 3)...

...thology...

...ith advanced-stage colorectal cancerTissue han...

Diagnosis based on primary tu...

...urgery required to stabilize patient due to obstru...

...atients with clinically stable disease,...

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

...e sigmoidoscopy (ASCO Resource Levels:...

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

...No primary tissue availableProceed to recommendat...

...iagnosis based on metasta...

1.11 Clinically palpable metastatic...

...static disease on staging US or Chest X Ray or CT...

... Patients with mCRC for whom MDT considers...

...lecular testing...

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


Table 3. Recommendations on DiagnosisHaving tro...


...mendations on Staging (Tab...

...on: Patients diagnosed with...

1.1...

...exam (ASCO Resource Levels: Basic, Limited) (...

...rectal exam (ASCO Resource Levels: Enhanced, M...

...6Chest X-Ray and abdominal ultrasound (US) (ASC...

...hanced CT scan chest, abdomen, pelvis...

...n selected cases (such as for when MDT is d...

...on: Liver-only metastatic disease based on imag...

1.1...

...I or contrast-enhanced liver USa (if MDT available...

...contrast-enhanced liver USa (ASCO...

...ulation: Rectal pr...

...MRI pelvis rectal cancer protocol (ASCO Resource...

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


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


...rst-Line Treatment (Table 5...

... RAS unknown...

...e (ASCO Resource Levels: Basic) (S)726...

...luoropyrimidine if available, if not, referral...

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

...otherapy ± anti-VEGF (bevacizumab...

...WT and right-sided primary tumor

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

...erapy ± anti-VEGF (bevacizumab) (ASCO...

... RAS WT and left-sided primary...

...ublet chemotherapy (ASCO Resource Levels:...

...therapy ± anti-EGFR (ASCO Resource Level...

...blet chemotherapy ± anti-VEGF (be...

... RAS WT ± BRAF MUT, patients with good PS and wi...

...therapy (ASCO Resource Levels: Enh...

...chemotherapy ± anti-VEGF (bevacizumab) (ASCO Reso...

...preexisting neuropathy, elderly, comorbidities,...

...fluoropyrimidine (ASCO Resource Levels: Limi...

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

...6 RAS WT and preexisting neuropathy, el...

...S WT and very poor performance status (PS 3...

...status and dMMR or MSI-H and patients not...

....10 RAS MU...

...herapy (ASCO Resource Levels: Enhanced) (S)7264...

...t chemotherapy ± anti-VEGF (bevacizumab) (ASC...

...and patients with good PS and with...

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

...y offer triplet chemotherapy ± anti-VEGF (be...

...nd preexisting neuropathy, elderly, comorbi...

...le agent fluoropyrimidine (ASCO Re...

...gent fluoropyrimidine ± anti-VEGF (bevaci...

...atients treated with oxaliplatin-based d...

...achronous metastases, prior oxaliplatin-based c...

...atin-based chemotherapy for early-st...

...lifying Statement for First-Line immu...


...-Line TreatmentHaving trouble view...


...commendations on Second-Line Systemic Colorecta...

...ble pertains to Enhanced and Maximal settin...

...oxaliplatin in first lineIrinotecan or irino...

....2 Received irinotecan in first lineOxa...

...bevacizumab in first linePatients...

...eived bevacizumab in first line...

...ients may receive an alternate chemotherapy r...

...can-based chemotherapy ± ziv-afliberce...

...tecan-based chemotherapy ± ramuciruma...

...herapy + irinotecan-based chemotherapy if RAS...

...R therapy alone (if not candidate...

...RAS WT, received anti-EGFR in firs...

...tive chemotherapy (ASCO Resource Levels: Enhance...

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

...MUT(see full text guideline: Second-Line Syste...

...dMMR or MSI-highImmune checkpoint...


...Recommendations on Second-Line Systemic Colore...


...tions on Third-Line and Fourth-Line Systemic...

...table pertains to only Maximal settings, with p...

4.1 RAS wild type, and no prior anti...

...2 any RAS/BRAFRegorafenibb (if availabl...

...Immune checkpoint inhibitors (if not prev...

...ination of cetuximab with irinotecan is mo...


Table 7. Recommendations on Third-Line and Four...


...s on Liver-Directed Therapies in Patients wit...

...s table pertains to only Maximal setting...

....1 Patients with liver metastasesUpfront surge...

...ighly selected patients with liver meta...

... Patients with liver metastasesAblative therapie...

...imal Settings, when patients are deemed to have...

...ts with liver metastases*Hepatic arteri...

...s with liver metastases*Transarterial chemoemb...

...nts with liver metastases*Selective inter...

...Recommendations should be implemented in ce...


...ndations on Liver-Directed Therapies in Pati...


Summary Treatment Options for Late-St...

...proaches for the Primary Tumor...

....1 mCR...

...h risk of obstruction, significant ble...

...struction from primary tumor or from peritone...

...of obstruction, significant bleeding, perfora...

...uction from primary tumor or from p...

...on from primary tumor: stenting (ASCO...

...adiation Therapy of Primary Tumor...

...2 mRectalIf symptomatic primary recta...

...ystemic Treatme...

6.3 mCRC

...luoropyrimidines (ASCO Resource Levels: Lim...

...oropyrimidines plus oxaliplatin (ASCO Resou...

...otecan (ASCO Resource Levels: Enhanced) (S)726...

...oropyrimidines plus oxaliplatin (A...

...n (S) + anti-VEGF (ASCO Resource Lev...

...anti-EGFR (ASCO Resource Levels: Maxi...

...point inhibitors (ASCO Resource Level...

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

...or Metastatic Disease Post-Systemic Treatme...

...who have received systemic treatmentSyn...

...Treatment After Primary Tumor and Meta...

...CRC who have received surgery/abl...

...pyrimidines (ASCO Resource Levels: Limited) (S)7...

Fluoropyrimidines plus oxaliplatin (ASCO Resou...

...irinotecan (ASCO Resource Levels:...

...pyrimidines plus oxaliplatin (ASCO...


...y Treatment Options for Late-Stage Colorectal Canc...


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

...Patients with metastatic disease on ac...

...CO Resource Levels: Basic...

...tion (medical history and physical exam),...

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

...ource Levels: Limited

...l evaluation (medical history and physical...

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

...CO Resource Levels: Enhanced/Maximal

...cal evaluation (medical history and phy...

...est/ abdomen/ pelvis every 2–3 months (M)7264...

....2 Patients with metastatic disease pos...

...CO Resource Levels...

...aluation (medical history and physical exam) (S)7...

...st X-Ray and abdominal ultrasound every 6 m...

...Resource Levels: Limited...

Clinical evaluation (medical histo...

...chest/ abdomen/ pelvis every 6 months for...

...e Levels: Enhanced, Maximal...

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

...scans chest/ abdomen/ pelvis every 3–6 months...


...commendations on Surveillance/Follow-UpHaving tro...