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
...linical Question 1.What are the optimal methods...
Treatment
Treatme...
...Question 2.What are the optimal systemic treatme...
...ion 3.What are the optimal treatments for patie...
...al Question 4.What are the optimal...
...inical Question 5.What are selected liver-direct...
...al Question 6. What is a summary of...
...Question 7.What are the optimal on-tre...
...ecommendations on Symptom Managemen...
....1 Patients with advanced-stage colorect...
...Patients with clinically unstable disea...
....3 Patients with clinically unstable disease due t...
...tients with clinically unstable disease...
....5 Patients with clinically stable disea...
...sion + surgery of primary tumor (ASCO Resource Lev...
...on + multi-disciplinary specialized eva...
...ble 2. Recommendations on Symptom Manag...
...mendations on Diagnosis (Table 3...
...hology...
...Patients with advanced-stage colorectal cancerTis...
...based on primary tumor...
....7 Surgery required to stabilize pat...
...ents with clinically stable disease, pa...
...ents with clinically stable disease...
...xible sigmoidoscopy (ASCO Resource Levels...
...e sigmoidoscopy or colonoscopy (ASCO Resource...
...No primary tissue availableProceed to recom...
...iagnosis based on metastatic diseas...
...y palpable metastatic siteBiopsy palpable mass (e...
...tatic disease on staging US or Chest...
... Patients with mCRC for whom MDT co...
...ular testing...
...sis of mCRC based on primary tumor o...
...mmendations on DiagnosisHaving trouble viewing tab...
Recommendations on Staging (Table...
...ion: Patients diagnosed with mCRC...
....15
...rectal exam (ASCO Resource Levels:...
...rectal exam (ASCO Resource Levels: Enhanced, M...
...X-Ray and abdominal ultrasound (US) (ASCO Resourc...
...ontrast enhanced CT scan chest, abdomen, pel...
...selected cases (such as for when MD...
...r-only metastatic disease based on imaging...
....19
...r MRI or contrast-enhanced liver USa (if MDT avai...
...RI or contrast-enhanced liver USa (A...
...ion: Rectal primary...
...elvis rectal cancer protocol (ASCO...
...al endoscopic ultrasound (ASCO Resource Levels:...
...ommendations on StagingHaving trou...
First-Line Treatment (Table 5)
...RAS unknown...
...tive care (ASCO Resource Levels: Basic) (S)7264...
...fluoropyrimidine if available, if not, refe...
...chemotherapy (ASCO Resource Levels: Enh...
...hemotherapy ± anti-VEGF (bevacizumab)...
...T and right-sided primary tumor...
...emotherapy (ASCO Resource Levels:...
...emotherapy ± anti-VEGF (bevacizumab) (ASCO Resou...
...and left-sided primary tumor...
...emotherapy (ASCO Resource Levels: Enhanced...
...motherapy ± anti-EGFR (ASCO Resour...
...otherapy ± anti-VEGF (bevacizumab) (ASCO Resourc...
...BRAF MUT, patients with good PS and withou...
...iplet chemotherapy (ASCO Resource Levels:...
...chemotherapy ± anti-VEGF (bevacizumab) (ASCO...
...d preexisting neuropathy, elderly, comorbidit...
...fluoropyrimidine (ASCO Resource Levels: Limited,...
...oropyrimidine ± anti-VEGF (bevacizumab)...
...and preexisting neuropathy, elderly, comorbi...
...T and very poor performance status (PS...
...status and dMMR or MSI-H and patients not candida...
...0 RAS MU...
...chemotherapy (ASCO Resource Levels: Enhanced) (S...
...let chemotherapy ± anti-VEGF (bevaci...
...RAS MUT and patients with good PS and without ma...
...er triplet chemotherapy (ASCO Resource Levels...
...triplet chemotherapy ± anti-VEGF (b...
...2 RAS MUT and preexisting neuropa...
...nt fluoropyrimidine (ASCO Resource Levels: Lim...
...ingle agent fluoropyrimidine ± anti-VEGF (bevaci...
...treated with oxaliplatin-based doublet or tripl...
...hronous metastases, prior oxaliplatin-based...
...r oxaliplatin-based chemotherapy for...
...ualifying Statement for First-Line immunothe...
...irst-Line TreatmentHaving trouble viewing tabl...
...ns on Second-Line Systemic Colorectal Metas...
...pertains to Enhanced and Maximal settings, with p...
...oxaliplatin in first lineIrinotecan or...
...ceived irinotecan in first lineOxal...
...bevacizumab in first linePatients may receiv...
...ved bevacizumab in first l...
...y receive an alternate chemotherapy regi...
...notecan-based chemotherapy ± ziv-af...
OR irinotecan-based chemotherapy ±...
...FR therapy + irinotecan-based chemotherapy if RA...
...y alone (if not candidate for irinoteca...
...WT, received anti-EGFR in fir...
...chemotherapy (ASCO Resource Levels:...
...chemotherapy ± anti-VEGF therapy (A...
...0E MUT(see full text guideline: Sec...
...7 dMMR or MSI-highImmune checkpoint inhibitors...
...mmendations on Second-Line Systemic Colorectal Met...
...tions on Third-Line and Fourth-Line Systemic Col...
...s table pertains to only Maximal settings, with pr...
...pe, and no prior anti-EGFR therapyAnti...
...AS/BRAFRegorafenibb (if available) OR trif...
... dMMR/MSI-HImmune checkpoint inhibitors (i...
...tion of cetuximab with irinotecan is mor...
...commendations on Third-Line and Fo...
...mendations on Liver-Directed Therapies...
...e pertains to only Maximal settings...
...ith liver metastasesUpfront surgery of...
....2 Highly selected patients with liver meta...
....3 Patients with liver metastasesA...
...ximal Settings, when patients are deemed t...
...nts with liver metastases*Hepatic ar...
...5 Patients with liver metastases*Transar...
...ients with liver metastases*Selective internal...
...NOTE: Recommendations should be i...
...ommendations on Liver-Directed Therapies in...
...reatment Options for Late-Stage Colorecta...
...y Approaches for the Primary T...
...1 mCRC...
...isk of obstruction, significant bleeding, p...
...n from primary tumor or from peritone...
...sk of obstruction, significant bleeding, perf...
...ction from primary tumor or from peri...
...if obstruction from primary tumor: stenting...
...on Therapy of Primary Tumor...
6.2 mRectalIf symptomatic primary...
...mic Treatmen...
...3 mCRC
...ropyrimidines (ASCO Resource Levels: Limited) (S)7...
...dines plus oxaliplatin (ASCO Resource Le...
...R irinotecan (ASCO Resource Levels: Enhanced) (S...
...opyrimidines plus oxaliplatin (ASCO Resourc...
...an (S) + anti-VEGF (ASCO Resource Levels: Ma...
...GFR (ASCO Resource Levels: Maximal) (M)7...
...ck-point inhibitors (ASCO Resource Levels: M...
...R BRAF inhibitors (ASCO Resource Levels: Maxima...
...or Metastatic Disease Post-Systemic Treatment...
... mCRC who have received systemic treatmentSyn...
...Treatment After Primary Tumor and Metastases Surg...
...RC who have received surgery/abl...
...rimidines (ASCO Resource Levels: Limited) (S)7...
...opyrimidines plus oxaliplatin (ASCO Resour...
...SCO Resource Levels: Enhanced) (S)7264...
...ines plus oxaliplatin (ASCO Resource L...
...Summary Treatment Options for Late-Stage Color...
...ndations on Surveillance/Follow-Up (Table 1...
7.1 Patients with metastatic disease on active...
...Resource Levels: Basic...
...evaluation (medical history and phys...
...k (complete blood count, metabolic panel includ...
...CO Resource Levels: Limited...
...nical evaluation (medical history and phys...
...work (complete blood count, metabolic...
...ce Levels: Enhanced/Maximal...
Clinical evaluation (medical history a...
...CT scans chest/ abdomen/ pelvis ev...
...nts with metastatic disease post curative-i...
...esource Levels: Basic...
...luation (medical history and physical...
...ay and abdominal ultrasound every 6 months fo...
...Resource Levels: Limite...
...ation (medical history and physical...
...D CT scan chest/ abdomen/ pelvis every 6 mon...
...ource Levels: Enhanced, Ma...
...evaluation (medical history and physical exam...
...chest/ abdomen/ pelvis every 3–6 months f...
...ommendations on Surveillance/Follow-Up...