Key priorities for implementation

Key priorities for implementation

The following recommendations have been identified as priorities for implementation.

Diagnostic investigations

  • 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).

Staging of colorectal cancer

  • Offer contrast‑enhanced computed tomography (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.

  • 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.

Preoperative management of the primary tumour

  • 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.

Colonic stents in acute large bowel obstruction

  • 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.

Stage I colorectal cancer

  • The colorectal multidisciplinary team (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.

Imaging hepatic metastases

  • 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.

Chemotherapy for advanced and metastatic colorectal cancer

  • 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[1]) as second‑line treatment or

    • XELOX (capecitabine plus oxaliplatin) as first‑line treatment then FOLFIRI (folinic acid plus fluorouracil plus irinotecan[1]) as second‑line treatment.

Follow-up after apparently curative resection

  • 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).

Information about bowel function

  • 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.

[1] 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)