Professor Graeme Poston highlights the NICE guideline recommendations on the investigation, disease staging, treatment options, and follow up of colorectal cancer
  • Colonoscopy is the gold standard investigation to establish a diagnosis of colorectal cancer
  • CT colonography should only be used as a diagnostic alternative to colonoscopy in units demonstrating proficiency in this technique
  • At time of diagnosis, all patients should be offered a contrast-enhanced
    CT scan of the chest, abdomen, and pelvis to stage disease; all patients with rectal cancer should be offered a staging pelvic MRI scan
  • Management of primary rectal cancer depends on level of risk and potential for resection
  • Colonic stents to relieve acute large bowel obstruction should only be used for left-sided lesions and only after discussion between specialists
  • Adjuvant systemic chemotherapy should be offered to all patients with high-risk stage II colon and rectal cancers and all patients with stage III colon and rectal cancers after apparently curative surgery
  • Patients presenting with stage IV cancer should be managed jointly by the appropriate anatomically site-specific MDTs
  • The decision on further imaging of patients with liver-limited metastatic disease should be made by an experienced hepatobiliary MDT
  • Patients who are sufficiently fit should be offered a second-line of
    systemic chemotherapy when their disease progresses after receiving
    first-line chemotherapy
  • Offer appropriate follow up after apparently curative treatment for as long as the clinician and patient believe appropriate or until such time that the patient is not sufficiently fit to undergo further treatment
  • Patients should be fully informed of the impact of treatment on bowel function, and of the need for a stoma (either temporary or permanent).

NICE Clinical Guideline 131 on the diagnosis and management of people with colorectal cancer has been awarded the NHS Evidence Accreditation Mark. This Mark identifies the most robustly produced guidance available. See evidence.nhs.uk/accreditation for further details.

Colorectal cancer is the third-leading cause of death from cancer in the UK, with a lifetime risk of about 2% in England and Wales and a rising incidence.1 The outcomes for people with colorectal cancer are improving, but overall 5-year survival rates are still lower than 60%.2 There is a need for greater awareness of colorectal cancer and for appropriate referral to secondary care, to enable earlier diagnosis and optimal treatment.

There are many major uncertainties in the diagnosis and management of colorectal cancer, including the use of permanent stomas following surgery for rectal cancer and determination of which patients should be considered for referral for resection of colorectal cancer liver metastases (currently a 1000% difference exists in such referrals between the worst and best performing hospitals in England).2,3

This article summarises the NICE guideline on the diagnosis and management of people with colorectal cancer.4,5 The recommendations focus on the diagnosis and treatment of patients in secondary and tertiary care, but successful implementation is dependent upon understanding and appreciation of this guidance by healthcare professionals delivering primary care.

Investigation, diagnosis, and staging

Symptoms suspicious of colorectal cancer include any of those listed below combined with a possible mass on rectal or abdominal examination:

  • Recent alterations in bowel habit (over a number of weeks)
  • Altered blood in the stool (as opposed to bright red blood on toilet paper)
  • Recent weight loss
  • Symptoms and signs of anaemia.

A pathway for patients presenting with suspected colorectal cancer is shown in Figure 1 (below).4,5

Figure 1: Overview of pathway for patients with colorectal cancer4,5

graph

*If the local radiology service can demonstrate competency in this technique; †this guideline does not make recommendations on what surgery is appropriate for this group of patients or when it is appropriate
CT=computed tomography; SEMS=self-expanding metallic stent; MRI=magnetic resonance imaging; CEA=carcinoembryonic antigen
National Institute for Health and Care Excellence (NICE) (2011) CG131. Colorectal cancer: the diagnosis and management of colorectal cancer. London: NICE. Available from www.nice.org.uk/guidance/CG131 Reproduced with permission.


Diagnostic investigations

Colorectal cancer can be detected by a number of methods, including colonoscopy, barium enema/flexible sigmoidoscopy, and computed tomography (CT) colonography. NICE recommends that diagnosis be confirmed by colonoscopy in patients without a major co-morbidity (e.g. cardiac or respiratory disease of sufficient severity as to preclude bowel preparation, sedation, or lying flat).5 Flexible sigmoidoscopy followed by barium enema, as an alternative to colonoscopy, should only be offered to patients with major co-morbidity. A biopsy should be performed if a suspicious lesion is found unless such a procedure is contraindicated (e.g. patients with a blood-clotting disorder). Possible alternatives to colonoscopy include CT colonography (if the local radiology service can demonstrate competency in this technique) or flexible sigmoidoscopy and then barium enema. Diagnosis should be confirmed through a colonoscopy with biopsy, unless contraindicated. Patients who have experienced an incomplete colonoscopy can be offered a repeat colonoscopy, CT colonography, or a barium enema.4,5

Staging of colorectal cancer

Staging of cancer prior to treatment can identify characteristics that indicate local recurrence and determine a suitable treatment strategy to reduce local recurrence.

Contrast-enhanced CT of the chest, abdomen, and pelvis, should be performed to estimate disease stage for all patients diagnosed with colorectal cancer, unless contraindicated. Magnetic resonance imaging (MRI) can be used to assess the risk of local recurrence, as determined by anticipated resection margin, tumour, and lymph-node staging. Endorectal ultrasound should be offered to patients in whom MRI is contraindicated or if results show that the disease is amenable to local excision. The NICE guidance highlights that the findings of a digital rectal examination should not be included as part of the staging assessment.4,5

Management of local disease

Pre-operative management

The NICE Guideline Development Group defined three levels of risk for patients with rectal cancer, according to the risk of local recurrence, based on the TNM (tumour, nodes, metastasis) staging system.6,7 Based on this risk assessment, patients could proceed straight to surgery, be offered either short-course preoperative radiotherapy (SCPRT) or preoperative chemoradiotherapy (see below).

Healthcare professionals should speak to the patient about the risk of local recurrence, short-term and long-term morbidity, and late effects, as appropriate following discussion within the multidisciplinary team (MDT).

The NICE guideline includes a number of recommendations on preoperative management:4,5

  • Patients assessed as low risk should proceed directly to surgery. Preoperative treatment should not be offered solely with the intention of sphincter preservation (i.e. to prevent a colostomy)
  • If the primary rectal tumour appears resectable at presentation, SCPRT and immediate surgery should be considered for patients with moderate-risk operable rectal cancer
  • Preoperative chemoradiotherapy with an interval before surgery to allow tumour response and shrinkage:
    • is a potential treatment for tumours that are borderline between moderate and high risk
    • should be offered to individuals with high-risk operable rectal cancer
    • should be offered to individuals with locally advanced rectal cancer.

Colonic stents in acute large bowel obstruction

The operative mortality of emergency surgery for large bowel obstruction remains high (above 10%) and there are good population-based data that show better outcomes if patients presenting as emergencies in this setting undergo urgent colonic stenting as a bridge to urgent surgery.8

Contrast enema studies should not be used as the sole imaging modality in patients presenting with acute large bowel obstruction. If considering the use of a colonic stent, CT should be performed to confirm the diagnosis of mechanical obstruction and to determine whether the patient has metastatic disease or colonic perforation. The decision to insert a colonic stent should be made by the specialist team. A consultant colorectal surgeon, together with an endoscopist or a radiologist (or both) experienced in inserting colonic stents should decide whether this intervention should be used in patients presenting with acute large bowel obstruction.4,5

Stage I colorectal cancer

Stage I colorectal cancer refers to tumours that have extended either into the submucosa (T1) or into, but not beyond, the muscularis propria (T2) and in which there is no evidence of spread into the lymph nodes (N0). An early rectal cancer MDT should decide which treatment to offer to patients with stage I rectal cancer, taking into account previous treatments, such as radiotherapy.9 Further treatment should be offered to patients whose tumour has involved resection margins (<1 mm).4,5


Laparoscopic surgery

The NICE recommendations on laparoscopic surgery have been taken from Technology Appraisal 105.10 Laparoscopic surgery should be performed only by surgeons who have completed appropriate training in the technique and who perform this procedure often enough to maintain competence. Cancer networks and constituent trusts should ensure that any local laparoscopic colorectal surgical practice meets relevant criteria as part of their clinical governance arrangements. In making the decision about which procedure (open or laparoscopic) is undertaken, the following should all be considered: the suitability of the lesion for laparoscopic resection; the risks and benefits of the two procedures; the experience of the surgeon in both procedures.4,5,10

Adjuvant chemotherapy in rectal cancer

Pathological staging should be assessed prior to deciding whether to offer adjuvant chemotherapy. This treatment should be considered for patients with high-risk stage II and all stage III rectal cancer to reduce the risk of local and systemic recurrence. Capecitabine as monotherapy or oxaliplatin in combination with 5-fluorouracil and folinic acid are the recommended options for adjuvant treatment of patients with stage III (Dukes’ C) colon cancer.4,5,11

Management of metastatic disease

Patients presenting with stage IV colorectal cancer

Treatment should be prioritised to control symptoms arising from the primary tumour in patients with stage IV colorectal cancer. If both primary and metastatic tumours are considered resectable, anatomical site-specific MDTs should consider initial systemic treatment followed by surgery.

Imaging hepatic metastases

If the CT scan shows metastatic disease only in the liver and the patient has no contraindications to further treatment, a specialist hepatobiliary MDT should decide if further imaging is appropriate and or/needed to confirm surgery.4,5

Imaging extra-hepatic metastases

Contrast-enhanced CT of the chest, abdomen, and pelvis should be offered to patients who are being assessed for metastatic colorectal cancer. If intracranial disease is suspected, offer contrast-enhanced MRI of the brain. Imaging of the head, neck, and limbs should only be offered if involvement of these sites is suspected clinically. If the CT scan detects extra-hepatic metastases that could be amenable to further radical surgery, an anatomical site-specific MDT should decide whether a positron emission tomography-CT scan of the whole body is appropriate. If contrast-enhanced CT suggests disease in the pelvis, offer an MRI of the pelvis and discuss with the colorectal cancer MDT. If the diagnosis of extra-hepatic recurrence remains uncertain, the patient should be kept under clinical review and offered repeat imaging at intervals agreed between the healthcare professional and patient.4,5

Chemotherapy for advanced and metastatic colorectal cancer

The NICE guideline on the management of colorectal cancer includes recommendations on the use of the following agents and combinations for chemotherapy:4,5

  • Oxaliplatin and irinotecan in combination with fluoropyrimidines
  • Raltitrexed
  • Capecitabine and tegafur with uracil
  • Biological drugs.
Implementation tools

NICE has developed the following tools to support implementation of Clinical Guideline 131 on Colorectal cancer: the diagnosis and management of colorectal cancer. The tools are now available to download from the NICE website: www.nice.org.uk/CG131

Baseline assessment tool Audit
The baseline assessment tool is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.

Clinical audit tools Audit
Audit tools aim to assist organisations with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. They consist of audit criteria and data collection tool(s) and can be edited or adapted for local use.

Costing report commissioning icon
Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.

Costing template commissioning icon
Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets.

Electronic audit tool Audit
Electronic audit tools are developed to assist organisations with clinical audit and to ensure that practice is in line with the NICE recommendations.

Slide set Education and learning
The slides provide a framework for discussing the NICE guideline with a variety of audiences and can assist in local dissemination. This information does not supersede or replace the guidance itself.

Case study Education and learning
This case study has been developed as an exemplar case study of setting up ‘Early Rectal Cancer Multidisciplinary teams’.

Key to NICE implementation icons
commissioning icon NICE support for commissioners
  • Support package for commissioners and others for quality standards
  • NICE guide for commissioners
  • NICE cost impact support for guidance (selection from national report/local template/costing statement, dependent on topic)
Audit NICE support for service improvement systems and audit
  • Forward planner
  • ‘How to’ guides (generic advice on processes)
  • Local government briefings (with Centre for Public Health Excellence)
  • Baseline assessment tool for guidance
  • Audit support including electronic data collection tools
  • E-learning modules (commissioned)
Education and learning NICE support for education and learning
  • Clinical case scenarios
  • Learning packages including slide sets
  • Podcasts
  • Shared learning and other local best practice examples

Ongoing care and support

Follow up after resection can have several benefits, which include:

  • early detection of recurrent or metachronous disease
  • facilitation of audit
  • characterisation of late effects of treatment
  • health-related issues such as early detection of co-morbidities, screening, and delivery of lifestyle advice.

Therefore all patients with primary colorectal cancer undergoing treatment with curative intent should be offered follow up. This can be initiated through a clinic visit 4–6 weeks after potentially curative treatment. Patients should have regular surveillance with:4,5

  • 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).

If the results of surveillance colonoscopy 1 year after initial treatment are normal, consider further colonoscopic follow up after 5 years, and thereafter as determined by cancer networks. The timing of surveillance for patients with subsequent adenomas should be determined by the risk status of the adenoma. Reinvestigation should be initiated if there is any clinical, radiological, or biochemical suspicion of recurrent disease. Regular follow up can be stopped when both the patient and healthcare professional have discussed and agreed that the likely benefits no longer outweigh the risks of further tests or when the patient cannot tolerate further treatments.4,5 Currently, follow up for colorectal cancer is performed in secondary care, however studies are currently underway to address the feasibility and benefits of carrying out this process in primary care.

Patient information

Patients should be offered information on:4,5

  • potential benefits and risks of available treatment options (including no treatment), and the effect on bowel function prior to starting treatment12
  • the likelihood of having a stoma, why it might be necessary, and how long it might be needed for
  • managing the effects of treatment on their bowel function, including incontinence, diarrhoea, difficulty emptying bowels, bloating, excess flatus and diet, and where to go for help in the event of symptoms
  • support organisations or internet resources recommended by the clinical team.

Although the Guideline Development Group was not tasked with addressing primary care issues, there is a responsibility for primary care healthcare professionals to understand this guidance. Many patients will require several investigations to reach a diagnosis and have their disease staged accurately, and the impact of treatment, possible complications, and psychological effects on quality of life must not be underestimated.

Conclusion

The scope of the guideline was based on areas of uncertainty in practice. Analysis of the evidence, and even the availability of any relevant evidence, leaves some uncertainty as to how to manage particular situations. However, the guideline attempts to provide clinicians with an appropriate approach based on what evidence there is and an expert opinion.

The successful treatment of colorectal cancer is highly dependent on good multiprofessional and multidisciplinary working. This means that communication among the different groups must be of a very high standard and implementing guidelines in such an environment has its challenges in terms of agreement and practical uptake.

  • The NICE guideline on colorectal cancer focuses on secondary care management after initial referral by a GP
  • Commissioners should be aware of a possible increase in demand for investigation of colorectal cancer resulting from campaigns that raise awareness of bowel health
  • Providers have to report cancer diagnosis and treatment against several national targets; commissioners can review local performance using these measures
  • Clear care pathways for diagnosis and treatment should be specified by commissioners, taking into account local availability of key interventions (e.g. computed tomography colonoscopy)
  • Tariff prices:a
    • Colorectal surgery outpatient = £129 (new; single professional), £75 (follow up)
    • Colonoscopy (FZ26A) = £398.
  1. Office for National Statistics. Cancer Statistics registrations. Registrations of cancer diagnosed in 2009, England. Series MB1 40. London: ONS, 2011. Available at: www.ons.gov.uk/ons/taxonomy/index.html?nscl=Cancer
  2. Morris E, Forman D, Thomas J et al. Surgical management and outcomes of colorectal cancer liver metastases. Br J Surg 2010; 97 (7): 1110–1118.
  3. Morris E, Quirke P, Thomas J et al. Unacceptable variation in abdominoperineal excision rates for rectal cancer: time to intervene? Gut 2008; 57 (12): 1690–1697.
  4. National Institute for Health and Care Excellence. Colorectal cancer: the diagnosis and management of colorectal cancer. Clinical Guideline 131. London: NICE, 2011. Available at: www.nice.org.uk/CG131
  5. National Collaborating Centre for Cancer. Colorectal cancer: the diagnosis and management of colorectal cancer. Clinical Guideline 131. London: NICE, 2011. Available at: www.nice.org.uk/CG131
  6. Edge S, Byrd D, Compston C et al (editors). AJCC cancer staging manual. 7th Edition. Springer, New York, 2010.
  7. Sobin L, Gospodarowicz M, Wittekind C, eds. International Union Against Cancer (UICC) TNM classification of malignant tumors. 7th ed. Oxford: Wiley-Blackwell, 2009.
  8. Iversen L, Kratmann M, Bøje M, Laurberg S. Self-expanding metallic stents as bridge to surgery in obstructing colorectal cancer. Br J Surg 2011; 98 (2): 275–281.
  9. National Institute for Health and Care Excellence. Improving outcomes in colorectal cancers. London: NICE, 2004. Available at: www.nice.org.uk/guidance/CSGCC
  10. National Institute for Health and Care Excellence. Laparoscopic surgery for colorectal cancer. Technology Appraisal 105. London: NICE, 2006. Available at: www.nice.org.uk/guidance/TA105/Guidance/pdf
  11. National Institute for Health and Care Excellence. Capecitabine and oxaliplatin in the adjuvant treatment of stage III (Dukes’ C) colon cancer. Technology Appraisal 100. London: NICE, 2006. Available at: www.nice.org.uk/guidance/TA100/Guidance/pdf
  12. Andreyev H, Davidson S, Gillespie C et al. Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer. Gut 2011; 61 (2): 179–192.G