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

...Diagnosis...

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


Treatment

...Treatment...

...stion 2.What are the optimal systemic tre...


...uestion 3.What are the optimal treatments...


...estion 4.What are the optimal treatments f...


...l Question 5.What are selected liver-direc...


...Clinical Question 6. What is a summary...


...uestion 7.What are the optimal on-tr...


...Recommendation...

...1 Patients with advanced-stage colorectal cance...

...Patients with clinically unstable...

...tients with clinically unstable dise...

...th clinically unstable disease due to bowel ob...

...ients with clinically stable disease wi...

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

...sfusion + multi-disciplinary specialized e...


...commendations on Symptom Management...


...Recom...

...Pathology...

...tients with advanced-stage colorectal cance...

...Diagnosis based on pr...

...7 Surgery required to stabilize pat...

....8 Patients with clinically stable dis...

...ients with clinically stable disease,...

...exible sigmoidoscopy (ASCO Resource Lev...

...doscopy or colonoscopy (ASCO Resource Levels: Enh...

....10 No primary tissue availableProce...

...Diagnos...

...inically palpable metastatic siteBiopsy palp...

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

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

...Mole...

1.14 Diagnosis of mCRC based on primary...


.... Recommendations on Diagnosis Popul...


...Reco...

...Population:...

1.1...

...l rectal exam (ASCO Resource Levels: Basic,...

...ectal exam (ASCO Resource Levels: E...

...and abdominal ultrasound (US) (ASCO Reso...

...nhanced CT scan chest, abdomen, pelvis (ASCO...

....18PET/CT in selected cases (such as...

...Population: Liver-only...

1.1...

...ntrast-enhanced liver USa (if MDT av...

...er MRI or contrast-enhanced liver USa (ASCO Resou...

...Population: Rectal prim...

...20MRI pelvis rectal cancer protocol...

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


...ecommendations on Staging P...


...First-Line...

... RAS unknown...

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

...ngle agent fluoropyrimidine if available, if...

...otherapy (ASCO Resource Levels: Enhan...

...chemotherapy ± anti-VEGF (bevacizuma...

...WT and right-sided primary tumor...

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

Doublet chemotherapy ± anti-VEGF...

...nd left-sided primary tumor...

...otherapy (ASCO Resource Levels: En...

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

...otherapy ± anti-VEGF (bevacizumab) (ASCO Re...

...RAF MUT, patients with good PS and...

...erapy (ASCO Resource Levels: Enhanced) (S)...

...chemotherapy ± anti-VEGF (bevacizu...

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

...oropyrimidine (ASCO Resource Levels: Limited, Enh...

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

...preexisting neuropathy, elderly, como...

...T and very poor performance status (PS 3...

...ny RAS status and dMMR or MSI-H and patients no...

...10 RAS M...

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

...emotherapy ± anti-VEGF (bevacizumab...

2.11 RAS MUT and patients with good PS...

...offer triplet chemotherapy (ASCO Resour...

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

...and preexisting neuropathy, elderly, comor...

...agent fluoropyrimidine (ASCO Resource L...

...e agent fluoropyrimidine ± anti-VEGF (bev...

... Patients treated with oxaliplatin-based d...

...ronous metastases, prior oxaliplatin-ba...

...oxaliplatin-based chemotherapy for e...

...Qualifying Statement for First-Line imm...


...ine Treatment Population Rec...


...e pertains to Enhanced and Maximal settin...

...d oxaliplatin in first lineIrinotecan o...

...2 Received irinotecan in first lineOxalipla...

3.3 No bevacizumab in first linePat...

...d bevacizumab in first line...

...receive an alternate chemotherapy regimen ± beva...

...an-based chemotherapy ± ziv-aflibercept (when tre...

...tecan-based chemotherapy ± ramucirumab (when tre...

...GFR therapy + irinotecan-based chemo...

...erapy alone (if not candidate for irinotecan...

...received anti-EGFR in first line...

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

...lternative chemotherapy ± anti-VEGF therap...

...RAF V600E MUT(see full text guidelin...

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


...ecommendations on Second-Line Systemic Co...


...Recommendations on Thi...

...able pertains to only Maximal settings, with presu...

...ld type, and no prior anti-EGFR therapyAnti...

...BRAFRegorafenibb (if available) OR trifluridin...

...MMR/MSI-HImmune checkpoint inhibitors (if not pr...

...ination of cetuximab with irinotecan is more...


...Recommendations on Third-Line and Fourth-Li...


...Recom...

...pertains to only Maximal settings...

... Patients with liver metastasesUpfront surgery...

...Highly selected patients with liver metas...

...atients with liver metastasesAblative therap...

...ximal Settings, when patients are...

... Patients with liver metastases*Hepatic arter...

...ients with liver metastases*Transarterial...

...6 Patients with liver metastases*Selective...

* NOTE: Recommendations should be implemented in...


...e 8. Recommendations on Liver-Directed Therapies i...


...Su...

...Surgery Approache...

....1 mCRC

...h risk of obstruction, significant bleeding,...

...obstruction from primary tumor or from pe...

...k of obstruction, significant bleeding, perfor...

...truction from primary tumor or from peri...

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

...Radiation Therapy of P...

....2 mRectalIf symptomatic primary rectal tumor,...

...Systemic Tre...

...3 mCRC...

...uoropyrimidines (ASCO Resource Leve...

...luoropyrimidines plus oxaliplatin (ASCO Resource...

OR irinotecan (ASCO Resource Levels: Enha...

...midines plus oxaliplatin (ASCO Resource L...

...irinotecan (S) + anti-VEGF (ASCO Resour...

...GFR (ASCO Resource Levels: Maximal) (M)72...

...mmune check-point inhibitors (ASCO Resou...

...inhibitors (ASCO Resource Levels: Maximal) (W)7...

...Sur...

...who have received systemic treatmentSynchronized...

...Systemic Treatment A...

...o have received surgery/ablation...

...dines (ASCO Resource Levels: Limited) (S)7264...

...oropyrimidines plus oxaliplatin (ASCO Res...

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

...s plus oxaliplatin (ASCO Resource Levels: Max...


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


...Recommendations on Surveil...

...7.1 Patients wi...

...O Resource Levels: Basic...

...nical evaluation (medical history and physical e...

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

...ource Levels: Limited...

...inical evaluation (medical history...

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

...Resource Levels: Enhanced/...

...valuation (medical history and physical exam...

...CT scans chest/ abdomen/ pelvis eve...

...7.2 Patients with me...

...esource Levels: Ba...

...inical evaluation (medical history and physic...

AND chest X-Ray and abdominal ultrasound...

...Resource Levels: Limite...

...uation (medical history and physical exam), CEA...

...est/ abdomen/ pelvis every 6 months for 2 years,...

...rce Levels: Enhanced, Maximal...

...aluation (medical history and phys...

...st/ abdomen/ pelvis every 3–6 months for 2 ye...


...le 10. Recommendations on Surveillance/Follow...