Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Prevention of colorectal cancer in people with Lynch syndrome

1.1.1 Consider daily aspirin[1], to be taken for more than 2 years, to prevent colorectal cancer in people with Lynch syndrome.

To find out why the committee made the recommendation on prevention of colorectal cancer in people with Lynch syndrome and how it might affect practice, see rationale and impact.

1.2 Information for people with colorectal cancer

1.2.1 Provide people with colorectal cancer information about their treatment (both written and spoken) in a sensitive and timely manner throughout their care, tailored to their needs and circumstances. Make sure the information is relevant to them, based on the treatment they might have and the possible side effects. Also see the NICE guideline on patient experience in adult NHS services and the NICE guideline on decision-making and mental capacity.

1.2.2 Give people information on all treatment options for colorectal cancer available to them, including:

  • surgery, radiotherapy, systemic anti-cancer therapy or palliative care

  • the potential benefits, risks, side effects and implications of treatments, for example, possible effects on bowel and sexual function (see also recommendation 1.6.2), quality of life and independence.

1.2.3 Advise people with colorectal cancer of possible reasons why their treatment plan might need to change during their care, including:

  • changes from laparoscopic to open surgery or curative to non-curative treatment, and why this change may be the most suitable option for them

  • the likelihood of having a stoma, why it might be necessary and for how long it might be needed.

1.2.4 If recovery protocols (such as 'enhanced recovery after surgery', ERAS) are used, explain to people with colorectal cancer what these involve and their value in improving their recovery after surgery.

1.2.5 Ensure that appropriate specialists discuss possible side effects with people who have had surgery for colorectal cancer, including:

  • altered bowel, urinary and sexual function

  • physical changes, including anal discharge or bleeding.

    If relevant, have a trained stoma professional provide information on the care and management of stomas and on learning to live with a stoma.

1.2.6 Emphasise to people the importance of monitoring and managing side effects during non-surgical treatment to try to prevent permanent damage (for example, monitoring prolonged sensory symptoms after platinum-based chemotherapy treatment, which can be a sign that the dose needs to be reduced to minimise future permanent peripheral neuropathy).

1.2.7 Give people who have had treatments for colorectal cancer information about possible short-term, long-term, permanent and late side effects which can affect quality of life, including:

  • pain

  • altered bowel, urinary or sexual function

  • nerve damage and neuropathy

  • mental and emotional changes, including anxiety, depression, chemotherapy-related cognitive impairment, and changes to self-perception and social identity.

1.2.8 Prepare people for discharge after treatment for colorectal cancer by giving them advice on:

  • adapting physical activity to maintain their quality of life

  • diet, including advice on foods that can cause or contribute to bowel problems such as diarrhoea, flatulence, incontinence and difficulty in emptying the bowels

  • weight management, physical activity and healthy lifestyle choices (for example stopping smoking and reducing alcohol use)

  • how long their recovery might take

  • how, when and where to seek help if side effects become problematic.

To find out why the committee made the recommendations on information for people with colorectal cancer and how they might affect practice, see rationale and impact.

1.3 Management of local disease

People with rectal cancer

Treatment for people with early rectal cancer (cT1-T2, cN0, M0)

1.3.1 Offer one of the treatments shown in table 1 to people with early rectal cancer (cT1-T2, cN0, M0) after discussing the implications of each treatment and reaching a shared decision with the person about the best option.

Table 1 Implications of treatments for early rectal cancer (cT1-T2, cN0, M0)

Transanal excision (TAE), including transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery (TEMS)

Endoscopic submucosal dissection (ESD)

Total mesorectal excision (TME)

Type of procedure

Endoscopic/Surgery

Endoscopic

Surgery

Minimally invasive procedure

Yes

Yes

Possible

Resection of bowel (may have more impact on sexual and bowel function)

No

No

Yes

Stoma needed (a permanent or temporary opening in the abdomen for waste to pass through)

No

No

Possible

General anaesthetic needed (and the possibility of associated complications)

Yes

No, conscious sedation

Yes

Able to do a full thickness excision (better chance of removing cancerous cells and more accurate prediction of lymph node involvement)

Yes

No

Yes

Removal of lymph nodes (more accurate staging of the cancer so better chance of cure)

No

No

Yes

Conversion to more invasive surgery needed if complication

Possible

Possible

Possible

Further surgery needed depending on histology

Possible

Possible

Usually no

Usual hospital stay

1 to 2 days

1 to 2 days

5 to 7 days

External scarring

No

No

Yes

Possible complications include (in alphabetical order)

Abdominal pain

Bleeding

Mild anal incontinence

Perirectal abscess/sepsis and stricture (narrowing)

Perforation

Suture line dehiscence (wound reopening)

Urinary retention

Abdominal pain

Bleeding

Bloating

Perforation

Adhesions

Anastomotic leak (leaking of bowel contents into the abdomen)

Anastomotic stricture (narrowing at internal operation site)

Bleeding

Incisional hernia (hernia where the surgical incision was made)

Injury to neighbouring structures

Pelvic abscess

Urinary retention

Some of the potential complications shown in the table were identified from the evidence review, others based on committee's expertise.

To find out why the committee made the recommendation on treatment for people with early rectal cancer and how it might affect practice, see rationale and impact.

Preoperative treatment for people with rectal cancer

1.3.2 Do not offer preoperative radiotherapy to people with early rectal cancer (cT1-T2 cN0, M0), unless as part of a clinical trial.

1.3.3 Offer preoperative radiotherapy or chemoradiotherapy to people with rectal cancer that is cT1-T2, cN1-N2, M0, or cT3-T4, any cN, M0.

To find out why the committee made the recommendations on preoperative treatment for people with rectal cancer and how they might affect practice, see rationale and impact.

Surgery for people with rectal cancer

1.3.4 Offer surgery to people with rectal cancer (cT1-T2, cN1-N2, M0, or cT3-T4, any cN, M0) who have a resectable tumour.

1.3.5 Inform people with a complete clinical and radiological response to neoadjuvant treatment who wish to defer surgery that there is a risk of recurrence, and there are no prognostic factors to guide selection for deferral of surgery. For those who choose to defer, encourage their participation in a clinical trial and ensure that data is collected via a national registry.

To find out why the committee made the recommendations on surgery for people with rectal cancer and how they might affect practice, see rationale and impact.

Surgical technique for people with rectal cancer

1.3.6 Offer laparoscopic surgery for rectal cancer, in line with NICE technology appraisal guidance (see surgical techniques for rectal cancer in the NICE Pathway on colorectal cancer).

1.3.7 Consider open surgery if clinically indicated, for example by locally advanced tumours, multiple previous abdominal operations or previous pelvic surgery.

1.3.8 Only consider robotic surgery within established programmes that have appropriate audited outcomes.

1.3.9 Only consider transanal total mesorectal excision (TME) surgery in line with the NICE interventional procedures guidance; see surgical techniques for rectal cancer in the NICE Pathway on colorectal cancer. This recommends that transanal TME surgery should only be offered with:

  • special arrangements for clinical governance, consent and audit or research

  • surgeons who are experienced in transanal rectal resection and have had specific training in this procedure

  • the outcomes entered onto the appropriate national transanal TME registry.

To find out why the committee made the recommendations on surgical technique for people with rectal cancer and how they might affect practice, see rationale and impact.

People with locally advanced or recurrent rectal cancer

1.3.10 Consider referring people with locally advanced primary or recurrent rectal cancer that might potentially need multi-visceral or beyond-TME surgery to a specialist centre to discuss exenterative surgery.

To find out why the committee made the recommendation on locally advanced or recurrent rectal cancer and how it might affect practice, see rationale and impact.

Surgical volumes for rectal cancer operations

1.3.11 Hospitals performing major resection for rectal cancer should perform at least 10 of these operations each year.

1.3.12 Individual surgeons performing major resection for rectal cancer should perform at least 5 of these operations each year.

To find out why the committee made the recommendations on surgical volumes for rectal cancer operations and how they might affect services, see rationale and impact.

People with colon cancer

Preoperative treatment for people with colon cancer

1.3.13 Consider preoperative systemic anti-cancer therapy for people with cT4 colon cancer.

To find out why the committee made the recommendation on preoperative treatment for people with colon cancer and how it might affect practice, see rationale and impact.

Surgical technique for people with colon cancer

For advice on laparoscopic surgery in line with NICE technology appraisal guidance, see surgical techniques for colon cancer in the NICE Pathway on colorectal cancer.

People with either colon or rectal cancer

Duration of adjuvant chemotherapy for people with colorectal cancer

Patients with rectal cancer treated with long-course chemoradiotherapy are not covered by this recommendation.

1.3.14 For people with stage III colon cancer[2] (pT1-4, pN1-2, M0), or stage III rectal cancer[3] (pT1-4, pN1-2, M0) treated with short-course radiotherapy or no preoperative treatment, offer:

  • capecitabine in combination with oxaliplatin (CAPOX) for 3 months, or if this is not suitable

  • oxaliplatin in combination with 5-fluorouracil and folinic acid (FOLFOX) for 3 to 6 months, or

  • single-agent fluoropyrimidine (for example, capecitabine) for 6 months, in line with NICE technology appraisal guidance (see adjuvant treatment of stage III colon cancer in the NICE Pathway on colorectal cancer).

    Base the choice on the person's histopathology (for example pT1-T3 and pN1, and pT4 and/or pN2), performance status, any comorbidities, age and personal preferences.

To find out why the committee made the recommendation on duration of adjuvant chemotherapy for people with colorectal cancer and how it might affect practice, see rationale and impact.

Colonic stents in acute large bowel obstruction

1.3.15 Consider stenting for people presenting with acute left-sided large bowel obstruction who are to be treated with palliative intent.

1.3.16 Offer either stenting or emergency surgery for people presenting with acute left-sided large bowel obstruction if potentially curative treatment is suitable for them.

To find out why the committee made the recommendations on colonic stents in acute large bowel obstruction and how they might affect practice, see rationale and impact.

1.4 Molecular biomarkers to guide systemic anti-cancer therapy

Also see the NICE diagnostics guidance on molecular testing strategies for Lynch syndrome in people with colorectal cancer.

1.4.1 Test for RAS and BRAF V600E mutations in all people with metastatic colorectal cancer suitable for systemic anti-cancer treatment.

To find out why the committee made the recommendation on molecular biomarkers to guide systemic anti-cancer therapy and how it might affect practice, see rationale and impact.

1.5 Management of metastatic disease

People with asymptomatic primary tumour

1.5.1 Consider surgical resection of the primary tumour for people with incurable metastatic colorectal cancer who are receiving systemic anti-cancer therapy and have an asymptomatic primary tumour. Discuss the implications of the treatment options with the person before making a shared decision. See table 2.

Table 2 Factors to take into account when considering resection of the asymptomatic primary tumour

Advantages

Disadvantages

Resection of the asymptomatic primary tumour

Possible improvement in overall survival rate (based on low quality evidence from research)

Avoidance of primary tumour-related symptoms such as obstruction, perforation, bleeding and pain

Around 5 in 100 people will have severe postoperative complications (based on moderate quality evidence from research)

Systemic therapy still needed, and may be delayed if surgical complications occur

No resection (systemic anti-cancer therapy only)

Avoids surgery and the potential for postoperative complications

Around 20 in 100 people will develop primary tumour-related symptoms such as obstruction, perforation, bleeding and pain that need surgery (based on low quality evidence from research)

Advantages and disadvantages in table 2 are based on committee expertise unless otherwise indicated.
Quality of evidence (based on grading of recommendations, assessment, development and evaluations [GRADE]):
Moderate: true effect is probably close to the estimated effect.
Low: true effect might be markedly different from the estimated effect.

To find out why the committee made the recommendation on asymptomatic primary tumour and how it might affect practice, see rationale and impact.

Systemic anti-cancer therapy for people with metastatic colorectal cancer

1.5.2 For advice on systemic anti-cancer therapy for people with metastatic cancer, see managing metastatic colorectal cancer in the NICE Pathway on colorectal cancer.

To find out why the committee made the recommendation on systemic anti-cancer therapy for people with metastatic colorectal cancer and how it might affect practice, see rationale and impact.

People with metastatic colorectal cancer in the liver

1.5.3 Consider resection, either simultaneous or sequential, after discussion by a multidisciplinary team with expertise in resection of disease in all involved sites.

1.5.4 Consider perioperative systemic anti-cancer therapy if liver resection is a suitable treatment.

1.5.5 Consider chemotherapy with local ablative techniques for people with colorectal liver metastases that are unsuitable for liver resection after discussion by a specialist multidisciplinary team.

1.5.6 Do not offer selective internal radiation therapy (SIRT) as first-line treatment for people with colorectal liver metastases that are unsuitable for local treatment. For advice on SIRT in line with the NICE interventional procedures guidance, see managing liver metastases in the NICE Pathway on colorectal cancer. This recommends that SIRT should only be offered:

  • with special arrangements for clinical governance, consent, and audit or research to people who are chemotherapy intolerant or who have liver metastases that are refractory to chemotherapy

  • in the context of research to people who can have chemotherapy.

To find out why the committee made the recommendations on metastatic colorectal cancer in the liver and how they might affect practice, see rationale and impact.

People with metastatic colorectal cancer in the lung

1.5.7 Consider metastasectomy, ablation or stereotactic body radiation therapy for people with lung metastases that are suitable for local treatment, after discussion by a multidisciplinary team that includes a thoracic surgeon and a specialist in non-surgical ablation.

1.5.8 Consider biopsy for people with a single lung lesion to exclude primary lung cancer.

To find out why the committee made the recommendations on metastatic colorectal cancer in the lung and how they might affect practice, see rationale and impact.

People with metastatic colorectal cancer in the peritoneum

1.5.9 For people with colorectal cancer metastases limited to the peritoneum:

  • offer systemic anti-cancer therapy and

  • within a multidisciplinary team, discuss referral to a nationally commissioned specialist centre to consider cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).

To find out why the committee made the recommendation on metastatic colorectal cancer in the peritoneum and how it might affect practice, see rationale and impact.

1.6 Ongoing care and support

Follow-up for detection of local recurrence and distant metastases

1.6.1 For people who have had potentially curative surgical treatment for non-metastatic colorectal cancer, offer follow-up for detection of local recurrence and distant metastases for the first 3 years. Follow-up should include serum carcinoembryonic antigen (CEA) and CT scan of the chest, abdomen and pelvis.

To find out why the committee made the recommendation on follow-up for detection of local recurrence and distant metastases and how it might affect practice, see rationale and impact.

Management of low anterior resection syndrome

1.6.2 Give information on low anterior resection syndrome (LARS) to people who will potentially have sphincter-preserving surgery. Advise them to seek help from primary care if they think they have symptoms of LARS, such as:

  • increased frequency of stool

  • urgency with or without incontinence of stool

  • feeling of incomplete emptying

  • fragmentation of stool (passing small amounts little and often)

  • difficulty in differentiating between gas and stool.

1.6.3 Assess people with symptoms of LARS using a validated patient-administered questionnaire (for example, the LARS score).

1.6.4 Offer people with bowel dysfunction treatment for associated symptoms in primary care (such as dietary management, laxatives, anti-bulking agents, anti-diarrhoeal agents, or anti-spasmodic agents). Seek advice from secondary care if the treatment is not successful.

To find out why the committee made the recommendations on management of low anterior resection syndrome and how they might affect practice, see rationale and impact.

Terms used in this guideline

This section defines terms that have been used in a specific way for this guideline. For general definitions, please see the NICE glossary.

Beyond-TME surgery

Beyond total mesorectal excision (TME) surgery is when the tumour extends beyond what is achievable to resect by TME and needs more extensive surgery to achieve clear margins.

Major resection for rectal cancer

Major resection for rectal cancer means a surgical operation when part or all of the rectum is removed, including anterior resection and abdominoperineal resection.

Recovery protocols

Recovery protocols, such as 'enhanced recovery after surgery' (ERAS), are perioperative care pathways designed to promote early recovery for patients undergoing major surgery by optimising the person's health before surgery and maintaining health and functioning after surgery.

Social identity

Social identity is about changes to people's concept of themselves as a result of either their cancer, or the long-term side effects from treatment. For example, it could cover changes from being a previously fit person to someone who has physical or mental health problems, from being someone with the expectation of years to live to someone with a limited life expectancy, or the change from being a carer to becoming cared for.

TNM classification

This guideline uses the tumour, node, metastasis (TNM) classification developed by the Union for Interventional Cancer Control (UICC) to describe the stage of the cancer. Please refer to The TNM Classification of Malignant Tumours, 8th Edition[4] for further information. In this guideline early rectal cancer is defined as cT1-2, cN0, M0. cTNM refers to clinical classification based on evidence acquired before treatment, for example imaging, physical examination and endoscopy. pTNM refers to pathological classification based on histopathology.



[1] At the time of publication (January 2020), aspirin does 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 Prescribing guidance: prescribing unlicensed medicines for further information.
Commonly used aspirin doses in current practice are 150 mg or 300 mg.

[2] Although use of capecitabine with oxaliplatin chemotherapy (CAPOX) is common in UK clinical practice, at the time of publication (January 2020), oxaliplatin did not have UK marketing authorisation for use in combination with capecitabine and capecitabine did not have UK marketing authorisation for 3 months duration of adjuvant treatment in people with colon cancer. 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 Prescribing guidance: prescribing unlicensed medicines for further information.

[3] At the time of publication (January 2020), capecitabine with oxaliplatin (CAPOX) and oxaliplatin with 5-fluorouracil and folinic acid (FOLFOX) did not have UK marketing authorisations 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 Prescribing guidance: prescribing unlicensed medicines for further information.

[4] Brierley JD, Gospodarowicz MK, Wittekind C, eds. International Union Against Cancer (UICC). TNM Classification of Malignant Tumours, 8th edn. Oxford: Wiley Blackwell, 2017.

  • National Institute for Health and Care Excellence (NICE)