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
...iagnosis...
...tion 1.What are the optimal methods...
Treatment
...eatment
...cal Question 2.What are the optimal syste...
...Question 3.What are the optimal treatments for...
...l Question 4.What are the optimal...
...al Question 5.What are selected liver-directed...
...cal Question 6. What is a summary of the...
...uestion 7.What are the optimal on-treatment surv...
...ecommendations on Symptom Management...
...1 Patients with advanced-stage colorectal...
...h clinically unstable disease due to bowel obstru...
...atients with clinically unstable dis...
... Patients with clinically unstable disea...
...5 Patients with clinically stable disease wit...
...rgery of primary tumor (ASCO Resource Levels:...
...ion + multi-disciplinary specialized evaluati...
...ndations on Symptom ManagementHaving troubl...
...endations on Diagnosis (Table 3)...
Patholog...
....6 Patients with advanced-stage colorect...
...sis based on primary tum...
...equired to stabilize patient due to obstructio...
...Patients with clinically stable disease,...
1.9 Patients with clinically stable...
...xible sigmoidoscopy (ASCO Resource Level...
...oidoscopy or colonoscopy (ASCO Resource Leve...
...rimary tissue availableProceed to rec...
...gnosis based on metastatic disease
...cally palpable metastatic siteBiopsy p...
...2 Metastatic disease on staging US or Chest X...
...13 Patients with mCRC for whom MDT considers...
Molecular testing
...Diagnosis of mCRC based on primary t...
...ndations on Staging...
...ion: Patients diagnosed with mCRC
....15
...rectal exam (ASCO Resource Levels: Ba...
...l rectal exam (ASCO Resource Levels:...
...est X-Ray and abdominal ultrasound (US) (AS...
...enhanced CT scan chest, abdomen, pelvis (ASC...
...PET/CT in selected cases (such as for...
Population: Liver-only metastatic dis...
....19
...or contrast-enhanced liver USa (if MDT available)...
...ntrast-enhanced liver USa (ASCO Resource L...
...ation: Rectal primary...
...MRI pelvis rectal cancer protocol (ASCO Resourc...
...ctal endoscopic ultrasound (ASCO Resource...
...st-Line Treatme...
...RAS unknown...
...ative care (ASCO Resource Levels: Basic) (S)...
Single agent fluoropyrimidine if availab...
...oublet chemotherapy (ASCO Resource Levels: Enhan...
...otherapy ± anti-VEGF (bevacizumab)...
...WT and right-sided primary tumor...
Doublet chemotherapy (ASCO Resource Levels:...
...rapy ± anti-VEGF (bevacizumab) (ASCO Res...
...and left-sided primary tumor...
...t chemotherapy (ASCO Resource Levels: Enhanced) (...
...hemotherapy ± anti-EGFR (ASCO Resource L...
...R doublet chemotherapy ± anti-VEGF (bevacizum...
... BRAF MUT, patients with good PS and wit...
...let chemotherapy (ASCO Resource Le...
...iplet chemotherapy ± anti-VEGF (bevaci...
...AS WT and preexisting neuropathy, elde...
...gent fluoropyrimidine (ASCO Resource Levels: Limit...
...gle agent fluoropyrimidine ± anti-V...
...and preexisting neuropathy, elderly, comorbi...
...RAS WT and very poor performance status...
...RAS status and dMMR or MSI-H and patient...
...10 RAS M...
...rapy (ASCO Resource Levels: Enhanced) (S)7...
...t chemotherapy ± anti-VEGF (bevacizumab) (ASCO...
...1 RAS MUT and patients with good PS and wi...
...ffer triplet chemotherapy (ASCO Re...
...y offer triplet chemotherapy ± anti-VEGF (bevaci...
...RAS MUT and preexisting neuropathy, elderly...
...t fluoropyrimidine (ASCO Resource Levels: Limited...
...oropyrimidine ± anti-VEGF (bevacizumab...
...nts treated with oxaliplatin-based doublet...
2.14b Metachronous metastases, prior oxaliplatin-...
...in-based chemotherapy for early-st...
...ations on Second-Line Systemic Colorecta...
...recommendations pertain to Enhanced and M...
...eceived oxaliplatin in first lineIrinotecan o...
...eceived irinotecan in first lineOxaliplat...
... No bevacizumab in first linePatients ma...
...eived bevacizumab in first line...
...tients may receive an alternate che...
...irinotecan-based chemotherapy ± ziv-af...
...-based chemotherapy ± ramucirumab (when t...
...R therapy + irinotecan-based chemotherapy if...
...herapy alone (if not candidate for irinotecan) (AS...
...eceived anti-EGFR in first line...
...chemotherapy (ASCO Resource Levels: Enhanc...
...ive chemotherapy ± anti-VEGF therap...
3.6 BRAF V600E MUT(see full text guidel...
...MR or MSI-highImmune checkpoint inhibitors (if no...
Recommendations on Third-Line and Fourth-Line Sy...
...e recommendations pertain to only Maxima...
... RAS wild type, and no prior anti...
...RAS/BRAFRegorafenibb (if available) O...
...mmune checkpoint inhibitors (if not previou...
...ons on Liver-Directed Therapies in...
...e: These recommendations pertain to only Max...
... Patients with liver metastasesUpfr...
...selected patients with liver metastasesC...
...th liver metastasesAblative therapi...
...tings, when patients are deemed to have unresect...
...4 Patients with liver metastases*Hepatic ar...
...nts with liver metastases*Transarter...
...Patients with liver metastases*Selective inte...
...ommendations should be implemented...
...reatment Options for Late-Stage Colorectal...
...gery Approaches for the Primary Tumor...
...1 mCRC
...k of obstruction, significant bleeding, p...
...bstruction from primary tumor or from...
...sk of obstruction, significant bleeding,...
...R if obstruction from primary tumor or fr...
OR if obstruction from primary tumor: stenting (A...
...diation Therapy of Primary Tu...
...lIf symptomatic primary rectal tumor,...
...ic Treatment...
....3 mC...
...pyrimidines (ASCO Resource Levels: Limited) (S)...
...nes plus oxaliplatin (ASCO Resource Levels...
...(ASCO Resource Levels: Enhanced) (S)7264...
...midines plus oxaliplatin (ASCO Resource Leve...
...can (S) + anti-VEGF (ASCO Resource Levels: Ma...
...SCO Resource Levels: Maximal) (M)7...
...immune check-point inhibitors (ASCO Resource...
...R BRAF inhibitors (ASCO Resource Levels: Maxima...
...urgery for Metastatic Disease Post-Systemic...
... mCRC who have received systemic treatmentSynchr...
...temic Treatment After Primary Tumor and...
...C who have received surgery/ablat...
...dines (ASCO Resource Levels: Limited) (S)726...
...ines plus oxaliplatin (ASCO Resource Levels: Enh...
...irinotecan (ASCO Resource Levels: Enhance...
...midines plus oxaliplatin (ASCO Resource Levels...
...tions on Surveillance/Follow-Up...
...Patients with metastatic disease on active...
...CO Resource Levels...
...evaluation (medical history and physical exam), e...
...lood work (complete blood count, met...
...ource Levels: Limite...
...ion (medical history and physical exam), ever...
...work (complete blood count, metabo...
...e Levels: Enhanced/Maximal...
...luation (medical history and physical exam...
...st/ abdomen/ pelvis every 2–3 months (M)726...
...ith metastatic disease post curative-i...
ASCO Resource Levels:...
...evaluation (medical history and physical ex...
...X-Ray and abdominal ultrasound every 6 mon...
...Resource Levels: Lim...
...al evaluation (medical history and physical...
AND CT scan chest/ abdomen/ pelvis...
...O Resource Levels: Enhanced,...
...luation (medical history and physical exam), CEA e...
...T scans chest/ abdomen/ pelvis every 3–6 mon...