NICE Guidelines on Colorectal cancer

National Institute for Health and Care Excellence has released its 2020 released guidelines on Colorectal Cancer. This guideline covers managing colorectal (bowel) cancer in people aged 18 and over. It aims to improve the quality of life and survival for adults with colorectal cancer through the management of local disease and management of secondary tumours (metastatic disease).

Following are the major recommendations:

1. Prevention of colorectal cancer in people with Lynch syndrome

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

2. Information for people with colorectal cancer

• 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.
• 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.
• 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.
• 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.
• 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.

• Emphasize 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 minimize future permanent peripheral neuropathy).
• Give people who have had treatments for colorectal cancer information about possible short-term, long-term, permanent and late side effects which can affect the 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.
• Prepare people for discharge after treatment for colorectal cancer by giving them advice on:
• adapting the 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.

3. Management of local disease

People with rectal cancer

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

• 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)

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

Preoperative treatment for people with rectal cancer

• Do not offer preoperative radiotherapy to people with early rectal cancer (cT1-T2 cN0, M0), unless as part of a clinical trial.
• Offer preoperative radiotherapy or chemoradiotherapy to people with rectal cancer that is cT1-T2, cN1-N2, M0, or cT3-T4, any cN, M0.

Surgery for people with rectal cancer

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

Surgical technique for people with rectal cancer

• 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).
• Consider open surgery if clinically indicated, for example by locally advanced tumours, multiple previous abdominal operations or previous pelvic surgery.
• Only consider robotic surgery within established programmes that have appropriate audited outcomes.
• 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.

People with locally advanced or recurrent rectal cancer

• 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.

Surgical volumes for rectal cancer operations

• Hospitals performing major resection for rectal cancer should perform at least 10 of these operations each year.
• Individual surgeons performing major resection for rectal cancer should perform at least 5 of these operations each year.

People with colon cancer

Preoperative treatment for people with colon cancer

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

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.

• For people with stage III colon cancer (pT1-4, pN1-2, M0), or stage III rectal cancer (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.

Colonic stents in acute large bowel obstruction

• Consider stenting for people presenting with acute left-sided large bowel obstruction who are to be treated with palliative intent.
• Offer either stenting or emergency surgery for people presenting with acute left-sided large bowel obstruction if potentially curative treatment is suitable for them.

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.

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

5. Management of metastatic disease

People with asymptomatic primary tumour

• 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.

Systemic anti-cancer therapy for people with metastatic colorectal cancer

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

People with metastatic colorectal cancer in the liver

• Consider resection, either simultaneous or sequential, after discussion by a multidisciplinary team with expertise in resection of disease in all involved sites.
• Consider perioperative systemic anti-cancer therapy if liver resection is a suitable treatment.
• 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.
• 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.

People with metastatic colorectal cancer in the lung

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

People with metastatic colorectal cancer in the peritoneum

• 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).

6. Ongoing care and support

Follow-up for detection of local recurrence and distant metastases

• 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.

Management of low anterior resection syndrome

• 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.
• Assess people with symptoms of LARS using a validated patient-administered questionnaire (for example, the LARS score).
• 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 read the complete guidelines, click on the following link: www.nice.org.uk