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

...agnosis...

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


Treatment

...atment...

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


...ical Question 3.What are the optimal treatments...


...on 4.What are the optimal treatmen...


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


...ion 6. What is a summary of the optimal...


...stion 7.What are the optimal on-treat...


...tions on Symptom Management (Table 2)...

...ents with advanced-stage colorectal cancerClinicia...

...2 Patients with clinically unstable...

...Patients with clinically unstable disease due to...

...s with clinically unstable disease due...

...Patients with clinically stable disease...

...nsfusion + surgery of primary tumor (A...

...ulti-disciplinary specialized eval...


...le 2. Recommendations on Symptom M...


...mmendations on Diagnosis (Table 3...

...thology...

1.6 Patients with advanced-stage colorectal canc...

...based on primary tumor...

...ry required to stabilize patient due to obs...

...Patients with clinically stable di...

...ients with clinically stable disease, no palpabl...

...xible sigmoidoscopy (ASCO Resource Levels: Limi...

...ble sigmoidoscopy or colonoscopy (ASC...

...0 No primary tissue availableProceed to recommend...

...osis based on metastatic dis...

...lly palpable metastatic siteBiopsy pal...

1.12 Metastatic disease on stagin...

1.13 Patients with mCRC for whom MDT considers...

Molecular testi...

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


...endations on DiagnosisHaving trouble viewing tab...


...tions on Staging (Table 4)...

...pulation: Patients diagnosed with...

1.15

...ctal exam (ASCO Resource Levels: Basic, Limi...

...l exam (ASCO Resource Levels: Enhanc...

...16Chest X-Ray and abdominal ultrasound...

...st enhanced CT scan chest, abdomen, p...

...T in selected cases (such as for w...

...tion: Liver-only metastatic disease b...

....19...

...contrast-enhanced liver USa (if MDT available)...

...MRI or contrast-enhanced liver USa (ASCO Re...

Population: Rectal p...

...MRI pelvis rectal cancer protocol...

...al endoscopic ultrasound (ASCO Resour...


Table 4. Recommendations on Stagin...


First-Line Treatment (Tabl...

2.1 RAS unknown

...liative care (ASCO Resource Levels: Basic) (S)72...

...nt fluoropyrimidine if available, if...

...blet chemotherapy (ASCO Resource Leve...

...herapy ± anti-VEGF (bevacizumab) (ASCO Resource L...

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

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

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

...WT and left-sided primary tumor...

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

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

...R doublet chemotherapy ± anti-VEGF (bevaciz...

... BRAF MUT, patients with good PS and wit...

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

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

...and preexisting neuropathy, elderly, comorbidi...

...nt fluoropyrimidine (ASCO Resource Levels:...

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

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

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

...y RAS status and dMMR or MSI-H and patients n...

....10 RAS MU...

...oublet chemotherapy (ASCO Resource...

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

...and patients with good PS and without...

...triplet chemotherapy (ASCO Resource Le...

...plet chemotherapy ± anti-VEGF (bevac...

...RAS MUT and preexisting neuropathy...

...fluoropyrimidine (ASCO Resource Levels: Limited,...

...luoropyrimidine ± anti-VEGF (bevacizumab...

... Patients treated with oxaliplatin-ba...

...ous metastases, prior oxaliplatin-based chem...

...xaliplatin-based chemotherapy for early-stag...

...Statement for First-Line immunotherapy: At...


...st-Line TreatmentHaving trouble viewing table?...


...commendations on Second-Line Systemic Col...

...: This table pertains to Enhanced an...

...Received oxaliplatin in first lineIrinotecan...

... Received irinotecan in first lineOxal...

3.3 No bevacizumab in first linePatie...

...ved bevacizumab in first line...

...ients may receive an alternate chemother...

...irinotecan-based chemotherapy ± ziv-aflibercept...

...n-based chemotherapy ± ramuciruma...

...anti-EGFR therapy + irinotecan-based ch...

...apy alone (if not candidate for irinotecan) (ASC...

...AS WT, received anti-EGFR in first line

...motherapy (ASCO Resource Levels: Enhanced) (M)726...

...lternative chemotherapy ± anti-VEGF therapy (A...

...V600E MUT(see full text guideline: Second...

3.7 dMMR or MSI-highImmune checkpoint...


...Recommendations on Second-Line Systemic Col...


...on Third-Line and Fourth-Line Sys...

...te: This table pertains to only Maxi...

...ild type, and no prior anti-EGFR t...

...AFRegorafenibb (if available) OR t...

...-HImmune checkpoint inhibitors (if not prev...

...nation of cetuximab with irinotecan i...


...le 7. Recommendations on Third-Line and Fourth-L...


...mmendations on Liver-Directed Therapies i...

...table pertains to only Maximal settings...

...with liver metastasesUpfront surgery of met...

...elected patients with liver metastasesCombination...

...ents with liver metastasesAblative th...

...n Maximal Settings, when patients are deemed to ha...

...nts with liver metastases*Hepatic ar...

...tients with liver metastases*Transart...

...ents with liver metastases*Selective internal radi...

...TE: Recommendations should be implemented in cente...


...ble 8. Recommendations on Liver-Di...


...Treatment Options for Late-Stage Colorectal C...

...ry Approaches for the Primary Tu...

....1 mCRC...

...high risk of obstruction, significant bleedin...

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

...obstruction, significant bleeding, perforati...

...if obstruction from primary tumor or fr...

...if obstruction from primary tumor: ste...

...adiation Therapy of Primary Tum...

...talIf symptomatic primary rectal tumor, radiation...

...ic Treatment...

....3 mC...

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

...uoropyrimidines plus oxaliplatin (ASCO...

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

...imidines plus oxaliplatin (ASCO Resourc...

...an (S) + anti-VEGF (ASCO Resource Levels: Maximal)...

...R anti-EGFR (ASCO Resource Levels: Maximal)...

...k-point inhibitors (ASCO Resource Levels: Maxi...

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

...rgery for Metastatic Disease Post-Systemic Treatme...

...have received systemic treatmentSynchronized...

...Treatment After Primary Tumor and Metastases...

... mCRC who have received surgery...

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

...opyrimidines plus oxaliplatin (ASC...

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

...idines plus oxaliplatin (ASCO Resource Levels:...


...Treatment Options for Late-Stage Colorectal Ca...


...mmendations on Surveillance/Follow...

...ts with metastatic disease on acti...

...Resource Levels: Basic...

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

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

ASCO Resource Levels: Li...

...valuation (medical history and physical exam), e...

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

...ource Levels: Enhanced/Maximal...

...tion (medical history and physical ex...

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

...th metastatic disease post curative-int...

...CO Resource Levels:...

...aluation (medical history and physical ex...

...chest X-Ray and abdominal ultrasound ev...

...ource Levels: Limited...

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

...ND CT scan chest/ abdomen/ pelvis every 6 months...

...CO Resource Levels: Enhanced, Maxim...

Clinical evaluation (medical history and phy...

...ans chest/ abdomen/ pelvis every 3–6 month...


...ommendations on Surveillance/Follo...