Update information

Update information

July 2018: Recommendations on the use of tegafur with uracil in section 1.3.4 have been updated.

November 2017: The reference to NICE technology appraisal guidance 176 in section 1.3.4 has been replaced with a reference to cetuximab and panitumumab for previously untreated metastatic colorectal cancer (NICE technology appraisal guidance 439).

December 2014: New recommendations on surgery and colonic stents in acute large bowel obstruction and on stage I rectal cancer have been added to sections 1.2.2 and 1.2.4.

Recommendations are marked as [new 2014], [2011], [2006] or [2003]:

[new 2014] indicates that the evidence has been reviewed and the recommendation has been added or updated.

[2011] indicates that the evidence has not been reviewed since the original guideline.

[2006] indicates that the evidence has not been reviewed since the publication of NICE technology appraisal guidance on laparoscopic surgery for colorectal cancer and capecitabine and oxaliplatin in the adjuvant treatment of stage III (Dukes' C) colon cancer respectively.

[2003] indicates that the evidence has not been reviewed since the publication of NICE technology appraisal guidance on capecitabine and tegafur with uracil for metastatic colorectal cancer.

Strength of recommendations

Some recommendations can be made with more certainty than others. The Guideline Development Group makes a recommendation based on the trade‑off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the Guideline Development Group is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision (see also patient-centred care).

Interventions that must (or must not) be used

We usually use 'must' or 'must not' only if there is a legal duty to apply the recommendation. Occasionally we use 'must' (or 'must not') if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions that should (or should not) be used – a 'strong' recommendation

We use 'offer' (and similar words such as 'refer' or 'advise') when we are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. We use similar forms of words (for example, 'Do not offer…') when we are confident that an intervention will not be of benefit for most patients.

Interventions that could be used

We use 'consider' when we are confident that an intervention will do more good than harm for most patients, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient's values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.

Recommendation wording in guideline updates

NICE began using this approach to denote the strength of recommendations in guidelines that started development after publication of the 2009 version of 'The guidelines manual' (January 2009). This does not apply to any recommendations ending [2006] or [2003]. In particular, for recommendations labelled [2006] or [2003] the word 'consider' may not necessarily be used to denote the strength of the recommendation.

ISBN: 978-1-4731-0860-8

  • National Institute for Health and Care Excellence (NICE)