Colorectal CancerImplementing NICE guidance

November 2011

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 the third most common cancer 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

Stage I colorectal cancer +

Management of metastatic disease

Imaging hepatic metastases +

Chemotherapy for advanced and metastatic colorectal cancer

Ongoing care and support

Follow up after apparently curative resection +

Information about bowel function

Research recommendation

R

R

R

R

R

R

• 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:1

• 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:2

If the local radiology service can demonstrate competency in the technique of computed tomographic (CT) colonography it can be

Diagnostic investigations:3

• considered as an alternative to colonoscopy or flexible sigmoidoscopy with barium enema

• offered as an option to patients who have had an incomplete colonoscopy.

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

Staging of colorectal cancer

Management of local disease:1

Key research recommendation 1

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

Characteristics of rectal tumours predicted by MRI

High 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

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:1

Key research recommendation 2

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

Preoperative management of the primary tumour:2

R

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:

Colonic stents in acute large bowel obstruction

• confirm the diagnosis of mechanical obstruction, and to

• determine whether the patient has metastatic disease or colonic perforation

The colorectal MDT should consider further treatment for patients with locally excised, pathologically confirmed stage I cancer, taking into account

Stage I colorectal cancer:1

• pathological characteristics of the lesion

• imaging results and • previous treatments

Key research recommendation 3

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, cost-effectiveness and quality of life

Stage I colorectal cancer:2

R

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:1

Key research recommendation 4

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

Imaging hepatic metastases:2

R

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

Chemotherapy for advanced and metastatic colorectal cancer

Offer patients regular surveillance with:

Follow up after apparently curative resection:1

• 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)

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

Follow up after apparently curative resection:2

R

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

Information 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?

Click here to go to NICE Pathways website

NICE Pathway

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 moreVisit www.nice.org.uk/guidance/CG131 for:

•the guideline•NICE pathway •‘Understanding NICE guidance’•costing report•audit support•implementation advice – case studies•clinical case scenarios – chemotherapy options.

NICE is developing a quality standard for colorectal cancer,which will be published in Autumn 2012.

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