NICE: updated guidelines on the management of colorectal cancer

NICE has published updated guidelines on the management of colorectal cancer.

Key recommendations include the following:

• Consider daily aspirin for ≥2 years in people with Lynch syndrome.
• For early rectal cancer (cT1-T2, cN0, M0) offer transanal excision (TAE), endoscopic submucosal dissection (ESD) or total mesorectal excision (TME).
• Do not offer preoperative radiotherapy for early rectal cancer unless as part of a clinical trial.
• Offer surgery, preoperative radiotherapy or chemoradiotherapy for cT1-T2, cN1-N2, M0, or cT3-T4, any cN, M0 rectal cancer.
• Where surgery is deferred, encourage participation in a clinical trial and ensure data is collected via a national registry.
• Only consider robotic surgery within established programmes.
• Consider referral for locally-advanced primary or recurrent rectal cancer that might need multi-visceral or beyond-TME surgery.
• Specialist hospitals should perform ≥10 major resection for rectal cancer per year and individual surgeons should perform ≥5.
• Consider preoperative systemic anti-cancer therapy for cT4 colon cancer.
• For stage III colon or rectal cancer treated with short-course radiotherapy or no preoperative treatment, offer:

1. Capecitabine with oxaliplatin (CAPOX) for 3 months.
2. Oxaliplatin with 5-fluorouracil and folinic acid (FOLFOX) for 3-6 months
3. Fluoropyrimidine (e.g. capecitabine) for 6 months.

• Consider stenting for acute left-sided large bowel obstruction.
• Test for RAS and BRAF V600E mutations in people with metastatic CRC suitable for systemic anti-cancer treatment.
• For liver metastases consider:

1. Simultaneous or sequential resection.
2. Perioperative systemic anti-cancer therapy.
3. Chemotherapy with local ablative techniques.

• Do not offer selective internal radiation therapy (SIRT) as first-line treatment for liver metastases unsuitable for local treatment.
• 15. Consider metastasectomy, ablation or stereotactic body radiation therapy for lung metastases.
• 16. Consider biopsy for single lung lesions to exclude primary lung cancer.