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
...gnosis...
...ical Question 1.What are the optimal m...
Treatment
...atment...
...stion 2.What are the optimal systemic...
...ical Question 3.What are the optim...
...nical Question 4.What are the optim...
...on 5.What are selected liver-directed therap...
...linical Question 6. What is a summary of...
...linical Question 7.What are the optimal...
...on Symptom Management (Table 2)...
...nts with advanced-stage colorectal can...
....2 Patients with clinically unstable disease due...
...with clinically unstable disease du...
....4 Patients with clinically unstable dise...
...with clinically stable disease with...
...nsfusion + surgery of primary tumor...
...+ multi-disciplinary specialized evaluation (ASC...
...mendations on Symptom ManagementHaving troub...
...ations on Diagnosis (Table...
...hology
...atients with advanced-stage colorectal cancer...
...iagnosis based on primary tum...
...7 Surgery required to stabilize patient due to ob...
...th clinically stable disease, palpabl...
...atients with clinically stable disease,...
...ible sigmoidoscopy (ASCO Resource Le...
...le sigmoidoscopy or colonoscopy (AS...
....10 No primary tissue availableProceed to reco...
...based on metastatic disease...
...ally palpable metastatic siteBiopsy palp...
...tic disease on staging US or Chest X Ray or CT...
...nts with mCRC for whom MDT considers liver...
...lecular testing...
...osis of mCRC based on primary tumor or on m...
...ndations on Staging...
...opulation: Patients diagnosed...
1.15
...exam (ASCO Resource Levels: Basic, Limited) (S...
...ctal exam (ASCO Resource Levels: Enhanced, Maxima...
...t X-Ray and abdominal ultrasound (US) (ASC...
...trast enhanced CT scan chest, abdo...
...ET/CT in selected cases (such as for when MD...
...lation: Liver-only metastatic disease ba...
1.19
...contrast-enhanced liver USa (if MDT...
...contrast-enhanced liver USa (ASCO...
...ation: Rectal primary...
...MRI pelvis rectal cancer protocol (ASCO Resour...
...doscopic ultrasound (ASCO Resource Level...
...t-Line Treatme...
...RAS unknown...
...alliative care (ASCO Resource Levels: Basic) (S)72...
...agent fluoropyrimidine if available, if...
...oublet chemotherapy (ASCO Resource Levels: En...
...therapy ± anti-VEGF (bevacizumab) (ASCO...
... RAS WT and right-sided primary...
...blet chemotherapy (ASCO Resource Levels: Enhanc...
...ublet chemotherapy ± anti-VEGF (be...
...AS WT and left-sided primary tumor
...herapy (ASCO Resource Levels: Enhanced) (S)7264...
...otherapy ± anti-EGFR (ASCO Resource Levels: Maxi...
...chemotherapy ± anti-VEGF (bevacizumab)...
2.4 RAS WT ± BRAF MUT, patients wit...
...hemotherapy (ASCO Resource Levels: Enhanced) (S)72...
...herapy ± anti-VEGF (bevacizumab) (...
...WT and preexisting neuropathy, elderly,...
...ingle agent fluoropyrimidine (ASCO...
...agent fluoropyrimidine ± anti-VEGF (bevaciz...
2.6 RAS WT and preexisting neuropath...
...very poor performance status (PS 3–4) or comorb...
...status and dMMR or MSI-H and patients not candida...
....10 RAS MUT
...blet chemotherapy (ASCO Resource Levels: Enhan...
...otherapy ± anti-VEGF (bevacizumab) (AS...
...AS MUT and patients with good PS and without...
...ay offer triplet chemotherapy (ASCO Reso...
...ay offer triplet chemotherapy ± anti-VEGF (beva...
...and preexisting neuropathy, elderly, comorbid...
...fluoropyrimidine (ASCO Resource Levels: L...
...nt fluoropyrimidine ± anti-VEGF (bevac...
...ients treated with oxaliplatin-based doublet or...
...Metachronous metastases, prior oxalip...
...latin-based chemotherapy for early-stage dis...
...endations on Second-Line Systemic Colo...
...hese recommendations pertain to Enhanced and...
...eceived oxaliplatin in first lineI...
...ed irinotecan in first lineOxaliplatin-based do...
...umab in first linePatients may rece...
...ved bevacizumab in first l...
...tients may receive an alternate chemotherapy reg...
...irinotecan-based chemotherapy ±...
...ecan-based chemotherapy ± ramucirumab (when tre...
...i-EGFR therapy + irinotecan-based chemothe...
...y alone (if not candidate for irin...
...WT, received anti-EGFR in first line...
...ternative chemotherapy (ASCO Resource Levels: Enh...
...ve chemotherapy ± anti-VEGF therapy (ASC...
...V600E MUT(see full text guideline: Second...
...MSI-highImmune checkpoint inhibitors (if n...
...ns on Third-Line and Fourth-Line Systemi...
...recommendations pertain to only Maximal settin...
...pe, and no prior anti-EGFR therapyAnti-EGF...
4.2 any RAS/BRAFRegorafenibb (if available) OR...
...R/MSI-HImmune checkpoint inhibitors (if no...
...endations on Liver-Directed Therapies...
...These recommendations pertain to only Maxima...
... Patients with liver metastasesUpfront...
...ected patients with liver metastasesCombi...
...atients with liver metastasesAblative therapies:...
In Maximal Settings, when patients are...
5.4 Patients with liver metastases*...
...5 Patients with liver metastases*T...
...Patients with liver metastases*Sele...
...commendations should be implemented in cente...
...ary Treatment Options for Late-Stage Color...
...Approaches for the Primary Tumor...
6.1 mCRC
...isk of obstruction, significant bleeding, per...
OR if obstruction from primary tumor or fro...
...k of obstruction, significant bleed...
OR if obstruction from primary tumor or...
...ion from primary tumor: stenting (...
...adiation Therapy of Primar...
...ymptomatic primary rectal tumor, radiatio...
...emic Treatme...
....3 mCRC
...luoropyrimidines (ASCO Resource Leve...
...imidines plus oxaliplatin (ASCO Resour...
...SCO Resource Levels: Enhanced) (S)7264...
...ropyrimidines plus oxaliplatin (ASCO R...
...(S) + anti-VEGF (ASCO Resource Leve...
OR anti-EGFR (ASCO Resource Levels...
...heck-point inhibitors (ASCO Resource Level...
...RAF inhibitors (ASCO Resource Levels: Maximal) (...
...urgery for Metastatic Disease Post-...
... mCRC who have received systemic treatmentS...
...c Treatment After Primary Tumor and Metastases S...
...5 mCRC who have received surgery/ablation...
...rimidines (ASCO Resource Levels: Limited) (S)...
...opyrimidines plus oxaliplatin (ASCO Resou...
...(ASCO Resource Levels: Enhanced) (...
...dines plus oxaliplatin (ASCO Resource Levels: Max...
...mendations on Surveillance/Follow-...
...ients with metastatic disease on active...
ASCO Resource Level...
Clinical evaluation (medical history...
...k (complete blood count, metabolic panel inc...
...ource Levels: Limited...
...ation (medical history and physical exam), every 1...
...work (complete blood count, metabolic panel incl...
...Resource Levels: Enhanced/Maxim...
...linical evaluation (medical histor...
...hest/ abdomen/ pelvis every 2–3 m...
...with metastatic disease post curative-intent...
...SCO Resource Levels:...
Clinical evaluation (medical history and physic...
...ay and abdominal ultrasound every 6 months...
...Resource Levels: Limited...
...valuation (medical history and physical exam),...
...CT scan chest/ abdomen/ pelvis every 6 mo...
...Resource Levels: Enhanced, Maximal...
...aluation (medical history and physic...
...ND CT scans chest/ abdomen/ pelvis every 3...