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Colorectal Cancer
Implementing NICE guidance
November 2011
Updated January 2015
NICE clinical guideline 131
What this presentation covers
Epidemiology
Scope
Key priorities for implementation
Costs and savings
Discussion
NICE Pathway
NHS Evidence
Find out more
Epidemiology
• Colorectal cancer is one of the most common cancers
in the UK
• 75% of colorectal cancer cases occur in people aged
65 and over
• Alcohol, inactivity, a diet with a high intake of red and
processed meat, family history and age all increase the
risk of colorectal cancer
Scope
• Colorectal cancer includes cancerous growths in the
colon, rectum and appendix
• The guideline covers key points in the diagnosis and
management of adults in all care settings with all
stages of colorectal cancer
• The guideline does not cover population-based
screening and surveillance of high-risk groups
Key priorities for implementation
Broad area
KPI area
Investigation,
diagnosis and
staging
Diagnostic investigations
Staging of colorectal cancer
Management of
local disease
Preoperative management of the primary tumour +
Colonic stents in acute large bowel obstruction
R
Stage I colorectal cancer + R
Management of
metastatic
disease
Imaging hepatic metastases +
Ongoing care
and support
Follow up after apparently curative resection +
R
R
R
Chemotherapy for advanced and metastatic colorectal
cancer
Information about bowel function
Research recommendation
R
Diagnostic investigations:1
• The recommendations on diagnostic
investigations refer to people whose condition is
being managed in secondary care
• Offer colonoscopy to patients without major
comorbidity, to confirm a diagnosis of colorectal
cancer
• If a lesion suspicious of cancer is detected,
perform a biopsy to obtain histological proof of
diagnosis, unless it is contraindicated
Diagnostic investigations:2
• Advise the patient that more than one
investigation may be necessary to confirm or
exclude a diagnosis of colorectal cancer
• Offer flexible sigmoidoscopy then barium enema
for patients with major comorbidity
Diagnostic investigations:3
If the local radiology service can demonstrate competency
in the technique of computed tomographic (CT)
colonography it can be
• considered as an alternative to colonoscopy or
flexible sigmoidoscopy with barium enema
• offered as an option to patients who have had an
incomplete colonoscopy.
Staging of colorectal cancer
Offer, unless contraindicated:
• contrast-enhanced CT of the chest, abdomen and
pelvis, to estimate the stage of disease, to all patients
diagnosed with colorectal cancer
• magnetic resonance imaging (MRI) to assess the risk of
local recurrence, as determined by anticipated
resection margin, tumour and lymph node staging, to all
patients with rectal cancer
Management of local disease:1
Key research recommendation 4
Strategies to integrate oncological surveillance with
optimising quality of life, reducing late effects, and
detecting second cancers in survivors of colorectal
cancer should be developed and explored
R
Management of local disease:2
Risk of local
recurrence
High
Characteristics of rectal tumours predicted by MRI
A threatened (< 1 mm) or breached resection margin or
Low tumours encroaching onto the inter-sphincteric plane or with
levator involvement
Moderate
Any cT3b or greater, in which the potential surgical margin is not
threatened or
Any suspicious lymph node not threatening the surgical resection
margin or
The presence of extramural vascular invasiona
Low
cT1 or cT2 or cT3a and
No lymph node involvement
a
This feature is also associated with high risk of systemic recurrence
Preoperative management of
the primary tumour:1
Do not offer short-course preoperative radiotherapy
(SCPRT) or chemoradiotherapy to patients with low-risk
operable rectal cancer unless as part of a clinical trial
Preoperative management of
the primary tumour:2
Key research recommendation 1
The effectiveness of preoperative chemotherapy should
be compared with short-course preoperative
radiotherapy (SCPRT), chemoradiotherapy or surgery
alone in patients with moderate-risk locally advanced
rectal cancer
Outcomes of interest are local control, toxicity, overall
survival, quality of life and cost effectiveness
R
Colonic stents in acute large
bowel obstruction
If considering the use of a colonic stent in patients
presenting with acute large bowel obstruction, offer CT of
the chest, abdomen and pelvis to:
• confirm the diagnosis of
mechanical obstruction, and to
• determine whether the patient
has metastatic disease or
colonic perforation
Stage I colorectal cancer:1
The colorectal MDT should consider further treatment
for patients with locally excised, pathologically
confirmed stage I cancer, taking into account
• pathological characteristics
of the lesion
• imaging results and
• previous treatments
Stage I colorectal cancer:2
Key research recommendation 2
An observational study should be conducted,
incorporating standardised assessment of pathological
prognostic factors, to assess the value of the proposed
prognostic factors in guiding optimal management in
patients with locally excised, pathologically confirmed
stage I cancer
Outcomes of interest are disease-free survival, overall
survival, local and regional control, toxicity, costeffectiveness and quality of life
R
Imaging hepatic metastases:1
If the CT scan shows metastatic disease confined to the
liver and the patient has no contraindications to further
treatment, referral to specialist hepatobiliary MDT should be
made.
The MDT should decide if further imaging is needed to
confirm if the patient is suitable for surgery.
Imaging hepatic metastases:2
Key research recommendation 3
A prospective trial should be conducted to investigate
the most clinically effective and cost-effective sequence
in which to perform MRI and PET-CT, after an initial CT
scan, in patients with colorectal cancer that has
metastasised to the liver, to determine whether the
metastasis is resectable
The outcomes of interest are reduction in inappropriate
laparotomies and improvement in overall survival
R
Chemotherapy for advanced and
metastatic colorectal cancer
When offering multiple chemotherapy drugs to patients with advanced
and metastatic colorectal cancer, consider one of the following
sequences of chemotherapy unless they are contraindicated:
• FOLFOX as first-line treatment then single agent irinotecan as
second-line treatment or
• FOLFOX as first-line treatment then FOLFIRI as second-line
treatment or
• XELOX as first-line treatment then FOLFIRI as second-line
treatment
Follow up after apparently
curative resection:1
Offer patients regular surveillance with:
• a minimum of two CTs of the chest, abdomen, and
pelvis in the first 3 years and
• regular serum carcinoembryonic antigen tests
(at least every 6 months in the first 3 years)
Follow up after apparently
curative resection:2
Key research recommendation 5
Colorectal cancer-specific patient-reported outcome
measures (PROMs) should be developed for use in
disease management and to inform outcome measures
in future clinical trials
R
Information on bowel function
Before starting treatment, offer
all patients information on all
treatment options available to
them (including no treatment)
and the potential benefits and
risks of these treatments,
including the effect on bowel
function
Costs and savings
The recommendations that are likely to have the greatest
resource impact at a local level cover:
• diagnostic investigations
• adjuvant chemotherapy for patients with high-risk stage II
colon cancer
• imaging for suspected metastases
• chemotherapy for advanced and metastatic colorectal
cancer
Discussion
• How does our current practice need to change to reflect
this guideline?
• Who is going to lead on implementing this guideline and
developing an action plan?
• How does current practice using mixed treatment
chemotherapy options compare with the guidance?
• What training do we need so that we can implement this
guideline effectively?
• What patient information do we currently produce and
do we need to revise it?
NICE
Pathway
Click here to
go to NICE
Pathways
website
NHS Evidence
Visit NHS
Evidence for
the best
available
evidence on
all aspects of
colorectal
cancer
Click here to
go to the NHS
Evidence
website
Find out more
Visit www.nice.org.uk/guidance/CG131 for:
•
•
•
•
•
•
•
the guideline
NICE pathway
‘Understanding NICE guidance’
costing report
audit support
shared learning
clinical case scenarios – chemotherapy options.
NICE has developed a quality standard for colorectal cancer.
NB. Not part of presentation
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