1 Recommendations

1.1 Investigation, diagnosis and staging

The recommendations in section 1.1 refer to people whose condition is being managed in secondary care. For recommendations for urgent referral from primary care for patients with suspected colorectal cancer see suspected cancer: recognition and referral.

1.1.1 Diagnostic investigations

1.1.1.1 Advise the patient that more than one investigation may be necessary to confirm or exclude a diagnosis of colorectal cancer. [2011]

1.1.1.2 Offer colonoscopy to patients without major comorbidity, to confirm a diagnosis of colorectal cancer. If a lesion suspicious of cancer is detected, perform a biopsy to obtain histological proof of diagnosis, unless it is contraindicated (for example, patients with a blood clotting disorder). [2011]

1.1.1.3 Offer flexible sigmoidoscopy then barium enema for patients with major comorbidity. If a lesion suspicious of cancer is detected perform a biopsy unless it is contraindicated. [2011]

1.1.1.4 Consider computed tomographic (CT) colonography as an alternative to colonoscopy or flexible sigmoidoscopy then barium enema, if the local radiology service can demonstrate competency in this technique. If a lesion suspicious of cancer is detected on CT colonography, offer a colonoscopy with biopsy to confirm the diagnosis, unless it is contraindicated. [2011]

1.1.1.5 Offer patients who have had an incomplete colonoscopy:

  • repeat colonoscopy or

  • CT colonography, if the local radiology service can demonstrate competency in this technique or

  • barium enema. [2011]

1.1.2 Staging of colorectal cancer

1.1.2.1 Offer contrast‑enhanced CT of the chest, abdomen and pelvis, to estimate the stage of disease, to all patients diagnosed with colorectal cancer unless it is contraindicated. No further routine imaging is needed for patients with colon cancer. [2011]

1.1.2.2 Offer magnetic resonance imaging (MRI) to assess the risk of local recurrence, as determined by anticipated resection margin, tumour and lymph node staging, to all patients with rectal cancer unless it is contraindicated. [2011]

1.1.2.3 Offer endorectal ultrasound to patients with rectal cancer if MRI shows disease amenable to local excision or if MRI is contraindicated. [2011]

1.1.2.4 Do not use the findings of a digital rectal examination as part of the staging assessment. [2011]

1.2 Management of local disease

1.2.1 Preoperative management of the primary tumour

For the purposes of this guideline we have defined three different risk groups of patients with rectal cancer, according to the risk of local recurrence. These groups are defined in table 1.

Table 1 Risk of local recurrence for rectal tumours as predicted by MRI

Risk of local recurrence

Characteristics of rectal tumours predicted by MRI

High

  • A threatened (<1 mm) or breached resection margin or

  • Low tumours encroaching onto the inter‑sphincteric plane or with levator involvement

Moderate

  • Any cT3b or greater, in which the potential surgical margin is not threatened or

  • Any suspicious lymph node not threatening the surgical resection margin or

  • The presence of extramural vascular invasion[a]

Low

  • cT1 or cT2 or cT3a and

  • No lymph node involvement

[a] This feature is also associated with high risk of systemic recurrence.

Patients whose primary rectal tumour appears resectable at presentation

1.2.1.1 Discuss the risk of local recurrence, short‑term and long‑term morbidity and late effects with the patient after discussion in the multidisciplinary team (MDT). [2011]

1.2.1.2 Do not offer short‑course preoperative radiotherapy (SCPRT) or chemoradiotherapy to patients with low‑risk operable rectal cancer (see table 1 for risk groups), unless as part of a clinical trial. [2011]

1.2.1.3 Consider SCPRT then immediate surgery for patients with moderate‑risk operable rectal cancer (see table 1 for risk groups). Consider preoperative chemoradiotherapy with an interval to allow tumour response and shrinkage before surgery for patients with tumours that are borderline between moderate and high risk. [2011]

1.2.1.4 Offer preoperative chemoradiotherapy with an interval before surgery to allow tumour response and shrinkage (rather than SCPRT), to patients with high‑risk operable rectal cancer (see table 1 for risk groups). [2011]

Patients whose primary colon or rectal tumour appears unresectable or borderline resectable

1.2.1.5 Discuss the risk of local recurrence and late toxicity with patients with rectal cancer after discussion in the MDT. [2011]

1.2.1.6 Offer preoperative chemoradiotherapy with an interval before surgery, to allow tumour response and shrinkage, to patients with high‑risk locally advanced rectal cancer. [2011]

1.2.1.7 Do not offer preoperative chemoradiotherapy solely to facilitate sphincter‑sparing surgery to patients with rectal cancer. [2011]

1.2.1.8 Do not routinely offer preoperative chemotherapy alone for patients with locally advanced colon or rectal cancer unless as part of a clinical trial. [2011]

1.2.2 Colonic stents in acute large bowel obstruction

1.2.2.1 If considering the use of a colonic stent in patients presenting with acute large bowel obstruction, offer CT of the chest, abdomen and pelvis to confirm the diagnosis of mechanical obstruction, and to determine whether the patient has metastatic disease or colonic perforation. [2011]

1.2.2.2 Do not use contrast enema studies as the only imaging modality in patients presenting with acute large bowel obstruction. [2011]

1.2.2.3 For patients with acute left‑sided large bowel obstruction caused by colorectal cancer that is potentially curable, and for whom surgery is suitable:

  • Resuscitate patients and explain to them and their family members or carers (as appropriate) that acute bowel obstruction can initially be managed either with emergency surgery or a colonic stent, and that there is no clear evidence that one treatment is better than the other. [new 2014]

  • Offer patients the chance to take part in a randomised controlled trial[2] (if available) that compares emergency surgery with colonic stent insertion to initially manage acute bowel obstruction. [new 2014]

1.2.2.4 For patients with acute left‑sided large bowel obstruction caused by colorectal cancer that is not potentially curable, or for whom surgery is unsuitable: [new 2014]

  • Resuscitate patients with acute large bowel obstruction, then consider placing a self‑expanding metallic stent to initially manage a left‑sided complete or near‑complete colonic obstruction. [2011]

  • A consultant colorectal surgeon should consider inserting a colonic stent in patients presenting with acute large bowel obstruction. They should do this together with an endoscopist or a radiologist (or both) who is experienced in using colonic stents. [2011]

1.2.2.5 Do not place self‑expanding metallic stents:

  • in low rectal lesions or

  • to relieve right‑sided colonic obstruction or

  • if there is clinical or radiological evidence of colonic perforation or peritonitis. [2011]

1.2.2.6 Do not dilate the tumour before inserting the self‑expanding metallic stent. [2011]

1.2.2.7 Only a healthcare professional experienced in placing colonic stents who has access to fluoroscopic equipment and trained support staff should insert colonic stents. [2011]

1.2.3 Stage I colorectal cancer

1.2.3.1 The colorectal MDT should consider further treatment for patients with locally excised, pathologically confirmed stage I cancer, taking into account pathological characteristics of the lesion, imaging results and previous treatments. [2011]

1.2.3.2 Offer further treatment to patients whose tumour had involved resection margins (less than 1 mm). [2011]

1.2.4 Stage I rectal cancer

1.2.4.1 An early rectal cancer MDT[3] should decide which treatment to offer to patients with stage I rectal cancer, taking into account previous treatments, such as radiotherapy. [2011]

1.2.4.2 After discussion in the MDT responsible for the management of stage I rectal cancer, discuss uncertainties about the potential risks and benefits of all treatment options with patients and their family members and carers (as appropriate), taking into account each patient's circumstances. [new 2014]

1.2.4.3 Explain to patients and their family members or carers (as appropriate) that there is very little good‑quality evidence comparing treatment options for stage I rectal cancer. [new 2014]

1.2.4.4 Offer patients the chance to take part in a randomised controlled trial (if available) that compares treatment options for stage I rectal cancer. [new 2014]

1.2.5 Laparoscopic surgery

The recommendations in this section are from laparoscopic surgery for colorectal cancer (NICE technology appraisal guidance 105).

1.2.5.1 Laparoscopic (including laparoscopically assisted) resection is recommended as an alternative to open resection for individuals with colorectal cancer in whom both laparoscopic and open surgery are considered suitable. [2006]

1.2.5.2 Laparoscopic colorectal surgery should be performed only by surgeons who have completed appropriate training in the technique and who perform this procedure often enough to maintain competence. The exact criteria to be used should be determined by the relevant national professional bodies. Cancer networks and constituent trusts should ensure that any local laparoscopic colorectal surgical practice meets these criteria as part of their clinical governance arrangements. [2006]

1.2.5.3 The decision about which of the procedures (open or laparoscopic) is undertaken should be made after informed discussion between the patient and the surgeon. In particular, they should consider:

  • the suitability of the lesion for laparoscopic resection

  • the risks and benefits of the two procedures

  • the experience of the surgeon in both procedures. [2006]

1.2.6 Adjuvant chemotherapy in rectal cancer

1.2.6.1 Assess pathological staging after surgery, before deciding whether to offer adjuvant chemotherapy. [2011]

1.2.6.2 Consider adjuvant chemotherapy for patients with high‑risk stage II and all stage III rectal cancer to reduce the risk of local and systemic recurrence. [2011]

1.2.7 Adjuvant chemotherapy for high-risk stage II colon cancer

1.2.7.1 Consider adjuvant chemotherapy after surgery for patients with high‑risk stage II colon cancer. Fully discuss the risks and benefits with the patient. [2011]

1.2.8 Adjuvant chemotherapy for stage III colon cancer

The recommendations in this section are from capecitabine and oxaliplatin in the adjuvant treatment of stage III (Dukes' C) colon cancer (NICE technology appraisal guidance 100).

1.2.8.1 The following are recommended as options for the adjuvant treatment of patients with stage III (Dukes' C) colon cancer following surgery for the condition:

  • capecitabine as monotherapy

  • oxaliplatin in combination with 5‑fluorouracil and folinic acid. [2006]

1.2.8.2 The choice of adjuvant treatment should be made jointly by the individual and the clinicians responsible for treatment. The decision should be made after an informed discussion between the clinicians and the patient; this discussion should take into account contraindications and the side‑effect profile of the agent(s) and the method of administration as well as the clinical condition and preferences of the individual. [2006]

1.3 Management of metastatic disease

1.3.1 Patients presenting with stage IV colorectal cancer

1.3.1.1 Prioritise treatment to control symptoms if at any point the patient has symptoms from the primary tumour. [2011]

1.3.1.2 If both primary and metastatic tumours are considered resectable, anatomical site‑specific MDTs should consider initial systemic treatment followed by surgery, after full discussion with the patient. The decision on whether the operations are done at the same time or separately should be made by the site‑specialist MDTs in consultation with the patient. [2011]

1.3.2 Imaging hepatic metastases

1.3.2.1 If the CT scan shows metastatic disease only in the liver and the patient has no contraindications to further treatment, a specialist hepatobiliary MDT should decide if further imaging to confirm surgery is suitable for the patient – or potentially suitable after further treatment – is needed. [2011]

1.3.3 Imaging extra-hepatic metastases

1.3.3.1 Offer contrast‑enhanced CT of the chest, abdomen and pelvis to patients being assessed for metastatic colorectal cancer. [2011]

1.3.3.2 If intracranial disease is suspected, offer contrast‑enhanced MRI of the brain. Do not offer imaging of the head, neck and limbs unless involvement of these sites is suspected clinically. [2011]

1.3.3.3 Discuss all imaging with the patient following review by the appropriate anatomical site‑specific MDT. [2011]

1.3.3.4 If the CT scan shows the patient may have extra‑hepatic metastases that could be amenable to further radical surgery, an anatomical site‑specific MDT should decide whether a positron emission tomography‑CT (PET‑CT) scan of the whole body is appropriate. [2011]

1.3.3.5 If contrast‑enhanced CT suggests disease in the pelvis, offer an MRI of the pelvis and discuss in the colorectal cancer MDT. [2011]

1.3.3.6 If the diagnosis of extra‑hepatic recurrence remains uncertain, keep the patient under clinical review and offer repeat imaging at intervals agreed between the healthcare professional and the patient. [2011]

1.3.4 Chemotherapy for advanced and metastatic colorectal cancer

Oxaliplatin and irinotecan in combination with fluoropyrimidines

1.3.4.1 When offering multiple chemotherapy drugs to patients with advanced and metastatic colorectal cancer, consider one of the following sequences of chemotherapy unless they are contraindicated:

  • FOLFOX (folinic acid plus fluorouracil plus oxaliplatin) as first‑line treatment then single agent irinotecan as second‑line treatment or

  • FOLFOX as first‑line treatment then FOLFIRI (folinic acid plus fluorouracil plus irinotecan[4]) as second‑line treatment or

  • XELOX (capecitabine plus oxaliplatin) as first‑line treatment then FOLFIRI (folinic acid plus fluorouracil plus irinotecan[4]) as second‑line treatment. [2011]

1.3.4.2 Decide which combination and sequence of chemotherapy to use after full discussion of the side effects and the patient's preferences. [2011]

Raltitrexed

1.3.4.3 Consider raltitrexed only for patients with advanced colorectal cancer who are intolerant to 5‑fluorouracil and folinic acid, or for whom these drugs are not suitable (for example, patients who develop cardiotoxicity). Fully discuss the risks and benefits of raltitrexed with the patient. [2011]

1.3.4.4 Prospectively collect data on quality of life, toxicity, response rate, progression‑free survival, and overall survival for all patients taking raltitrexed. [2011]

Capecitabine and tegafur with uracil

The recommendations in this section are from guidance on the use of capecitabine and tegafur with uracil for metastatic colorectal cancer (NICE technology appraisal guidance 61).

1.3.4.5 Oral therapy with capecitabine is recommended as an option for the first‑line treatment of metastatic colorectal cancer. [2003]

1.3.4.6 The choice of regimen (intravenous 5‑fluorouracil and folinic acid or capecitabine) should be made jointly by the individual and the clinician(s) responsible for treatment. The decision should be made after an informed discussion between the clinician(s) and the patient; this discussion should take into account contraindications and the side‑effect profile of the agents as well as the clinical condition and preferences of the individual. [2003]

1.3.4.7 The use of capecitabine to treat metastatic colorectal cancer should be supervised by oncologists who specialise in colorectal cancer. [2003]

1.4 Ongoing care and support

1.4.1 Follow-up after apparently curative resection

1.4.1.1 Offer follow‑up to all patients with primary colorectal cancer undergoing treatment with curative intent. Start follow‑up at a clinic visit 4–6 weeks after potentially curative treatment. [2011]

1.4.1.2 Offer patients regular surveillance with:

  • a minimum of two CTs of the chest, abdomen, and pelvis in the first 3 years and

  • regular serum carcinoembryonic antigen tests (at least every 6 months in the first 3 years). [2011]

1.4.1.3 Offer a surveillance colonoscopy at 1 year after initial treatment. If this investigation is normal consider further colonoscopic follow‑up after 5 years, and thereafter as determined by cancer networks. The timing of surveillance for patients with subsequent adenomas should be determined by the risk status of the adenoma. [2011]

1.4.1.4 Start reinvestigation if there is any clinical, radiological or biochemical suspicion of recurrent disease. [2011]

1.4.1.5 Stop regular follow‑up:

  • when the patient and the healthcare professional have discussed and agreed that the likely benefits no longer outweigh the risks of further tests or

  • when the patient cannot tolerate further treatments. [2011]

1.4.2 Information about bowel function

1.4.2.1 Before starting treatment, offer all patients information on all treatment options available to them (including no treatment) and the potential benefits and risks of these treatments, including the effect on bowel function. [2011]

1.4.2.2 Before surgery, offer all patients information about the likelihood of having a stoma, why it might be necessary, and how long it might be needed for. [2011]

1.4.2.3 Ensure a trained stoma professional gives specific information on the care and management of stomas to all patients considering surgery that might result in a stoma. [2011]

1.4.2.4 After any treatment, offer all patients specific information on managing the effects of the treatment on their bowel function. This could include information on incontinence, diarrhoea, difficulty emptying bowels, bloating, excess flatus and diet, and where to go for help in the event of symptoms. [2011]

1.4.2.5 Offer verbal and written information in a way that is clearly understood by patients and free from jargon. Include information about support organisations or internet resources recommended by the clinical team. [2011]



[2] At the time of publication (December 2014), the CReST trial was recruiting patients with acute bowel obstruction caused by suspected colorectal cancer for randomisation to either colonic stent insertion or emergency surgery.

[3] See Improving outcomes in colorectal cancer (NICE cancer service guidance)

[4] At the time of publication (November 2011), irinotecan did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

  • National Institute for Health and Care Excellence (NICE)