Colorectal cancer

Last reviewed: 4 Jun 2022
Last updated: 26 May 2022
26 May 2022

Recommendations for adjuvant therapy for stage 2 colon cancer from the American Society of Clinical Oncology (ASCO)

ASCO recommends that adjuvant chemotherapy should be offered to patients with stage IIA colon cancer and high-risk features, and patients with stage IIB and IIC colon cancer.

High-risk features are: perineural or lymphovascular invasion, poorly differentiated tumour grade, undifferentiated tumour grade, intestinal obstruction, tumour perforation, ≥10 tumour buds, or <12 lymph nodes in surgical specimen. The number of risk factors present should be considered in the shared decision-making process, because the presence of more than one risk factor may increase risk of recurrence.

Patients with high-risk stage IIA, or stage IIB or stage IIC colon cancer should be offered therapy for 3 to 6 months, after an individualised discussion of the potential benefits and harms of the treatment and its duration.

Adjuvant chemotherapy should not be offered routinely to people with stage IIA colon cancer without high-risk features.

See Management: approach

Original source of update

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • increasing age
  • rectal bleeding
  • change in bowel habit
  • rectal mass
  • positive family history
  • abdominal mass
More key diagnostic factors

Other diagnostic factors

  • anaemia
  • male sex
  • abdominal pain
  • weight loss and anorexia
  • abdominal distension
  • palpable lymph nodes
Other diagnostic factors

Risk factors

  • increasing age
  • family history
  • adenomatous polyposis coli mutation
  • Lynch syndrome (hereditary non-polyposis colorectal cancer)
  • MUTYH/MYH-associated polyposis
  • hamartomatous polyposis syndromes
  • inflammatory bowel disease
  • obesity
  • acromegaly
  • limited physical activity
  • lack of dietary fibre
More risk factors

Diagnostic investigations

1st investigations to order

  • full blood count
  • liver biochemistry
  • renal function
  • colonoscopy
  • CT colonography
  • double-contrast barium enema
  • CT scan of chest, abdomen, and pelvis
  • genetic testing
More 1st investigations to order

Investigations to consider

  • MRI pelvis rectal cancer protocol
  • transrectal endoscopic ultrasound
  • biopsy
  • carcinoembryonic antigen
  • PET scan
More investigations to consider

Emerging tests

  • advanced optical imaging techniques

Treatment algorithm

ACUTE

rectal cancer, suitable for surgery

rectal cancer, not suitable for surgery

colon cancer, suitable for surgery

colon cancer, not suitable for surgery

Contributors

Authors

David E. Stein, MD, FACS, FASCRS

Regional Chief of Surgery

MedStar Health

Baltimore

MD

Disclosures

DES declares that he has no competing interests.

David M. Lisle, MD

Associate Program Director

Department of Surgery

MedStar Franklin Square Medical Center

Baltimore

MD

Disclosures

DML declares that he has no competing interests.

Pallavi P. Kumar, MD

Division Director, Medical Oncology

Sinai and Northwest Hospital

LifeBridge Health

Alvin & Lois Lapidus Cancer Institute

Baltimore

MD

Disclosures

PPK declares that she has no competing interests.

Kamila A. Nowak-Choi, MD

Department of Radiation Oncology

MedStar Franklin Square Medical Center

Baltimore

MD

Disclosures

KANC declares that she has no competing interests.

Acknowledgements

Dr David E. Stein, Dr David M Lisle, Dr Pallavi P Kumarm, and Dr Kamila A Nowak-Choi would like to gratefully acknowledge Dr Juan L. Poggio, Dr Jascha Rubin, Dr Najjia Mahmoud, Dr Emily Carter Paulson, Dr Gary Atkin, Dr Anne Ballinger, Dr Mark O'Hara, Dr Mark Harrison, and Dr Robert Glynne-Jones, previous contributors to this topic.

Disclosures

JLP, JR, NM, ECP, MOH, GA, and AB declare that they have no competing interests. MH is the chair of the Mount Vernon Upper GI Tumour Site Specific Group and a member of the National Cancer Research Institute anal, rectal, and advanced colorectal groups. He has also received honoraria for speaking and has been supported to attend international meetings in gastrointestinal (GI) cancer from Roche. He has also received research funding from Pfizer for a trial in rectal cancer. RGJ is the chief medical adviser to the charity Bowel Cancer UK. He has received honoraria for lectures from Roche, Sanofi, and Pfizer. He has received funding for the EXTRA study, involving capecitabine and radiotherapy in anal cancer, published in the International Journal of Radiation Biology Physics. RGJ has also received funding and free cetuximab for an ongoing phase 1/2 study integrating cetuximab into chemoradiation in rectal cancer, and has an agreement from Roche to supply bevacizumab for 3 months to 60 patients in one randomised phase 2 study as neoadjuvant chemotherapy in rectal cancer (BACCHUS). He has also been supported by Roche to attend international meetings in GI cancer.

Peer reviewers

Susan Clark, BChir, MB

Consultant Colorectal Surgeon

St Mark's Hospital and Academic Institute

Northwick Park

Middlesex

UK

Disclosures

SC declares that she has no competing interests.

Steven Wexner, MD, FACS, FRCS, FRCS Ed, FASCRS, FAC

Chief of Staff

Chairman

Department of Colorectal Surgery

Cleveland Clinic

Weston

FL

Disclosures

SW declares that he has no competing interests.

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