[1] 16w The recommendations on laparoscopic surgery for colorectal cancer are covered by NICE's technology appraisal 105. 5

[2] 54w After fully discussing the risks and benefits with the patient, consider adjuvant chemotherapy for patients with stage II rectal cancer with high risk of recurrence and all patients with stage III rectal cancer, and for patients with stage II colon cancer with high risk of recurrence and all patients with stage III colon cancer.

[3] 20w • Offer contrast enhanced CT scanning of the chest, abdomen, and pelvis to patients being assessed for metastatic colorectal cancer.

[4] 16w • Discuss all imaging with the patient after review by the appropriate site specific multidisciplinary team.

[5] 44w • If the CT scan shows metastatic disease only in the liver and there are no contraindications to further treatment, a specialist hepatobiliary multidisciplinary team should decide if further imaging is needed to confirm whether surgery is suitable or potentially suitable after further treatment.

[6] 13w • If intracranial disease is suspected offer contrast enhanced MRI of the brain.

[7] 32w • If the CT scan shows possible extrahepatic metastases that could be amenable to further radical surgery, consider if positron emission tomography with computed tomography (PET-CT) of the whole body is appropriate.

[8] 27w • If contrast enhanced CT scanning suggests disease in the pelvis, offer an MRI of the pelvis PRACTICE and discuss management in the colorectal cancer multidisciplinary team.

[9] 25w • If the diagnosis of extrahepatic recurrence remains uncertain, keep the patient under clinical review and offer repeat imaging at intervals agreed with the patient.

[10] 117w The guideline deals with many major uncertainties in the diagnosis and treatment of colorectal cancer, including the uncertainty about which patients to refer for consideration of resection of colorectal cancer liver metastases (currently the best performing hospital refers 10 times as many patients as the worst performing hospital). 11 The guidance on referral for all patients with liver limited disease who are fit for further surgery (that they should be referred to specialist liver surgery multidisciplinary teams for decisions on further definitive imaging) will substantially increase the chance of such patients being offered potentially curative surgery. Successful treatment of colorectal cancer depends highly on good multiprofessional and multidisciplinary working, requiring effective communication among the different healthcare teams.

[11] 35w Contributors: All authors contributed to the conception and drafting of this article and revising it critically. They have all approved this version. GP (who is also chair of the Guideline Development Group) is the guarantor.

[12] 26w Funding: The National Collaborating Centre for Cancer was commissioned and funded by the National Institute for Health and Clinical Excellence to develop this guideline and summary.

[1] 31w This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

[2] 17w The supporting evidence statements and further information about the guidance are in the full version on bmj.com.

[3] 27w • For patients with major comorbidity, offer flexible sigmoidoscopy followed by a barium enema. If a lesion suspicious of cancer is detected perform a biopsy unless contraindicated.

[4] 49w • Consider computed tomographic colonography as an alternative to colonoscopy or to flexible sigmoidoscopy with a barium enema, if the local radiology service can show competency in this technique. If a lesion suspicious of cancer is detected, offer colonoscopy with biopsy to confirm the diagnosis, unless it is contraindicated.

[5] 9w • Offer patients who have had an incomplete colonoscopy:

[6] 21w -Repeat colonoscopy or -Computed tomographic colonography, if the local radiology service can show competency in this technique or -A barium enema.

[7] 9w The box explains the four stages of colorectal cancer.

[8] 29w • For all patients diagnosed with colorectal cancer offer contrast enhanced CT (computed tomography) scanning of the chest, abdomen, and pelvis to estimate disease stage, unless it is contraindicated.

[9] 53w • For all patients with rectal cancer offer MRI (magnetic resonance imaging) to assess the risk of local recurrence (as determined by anticipated resection margin and staging of the tumour and lymph nodes) unless it is contraindicated. If MRI shows disease amenable to local excision or if MRI is contraindicated, offer endorectal ultrasonography.

[10] 17w • Do not use the findings of a digital rectal examination as part of the staging assessment.

[11] 30w • 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.

[12] 27w • Before surgery offer all patients information about the likelihood of having a stoma, why it might be necessary, and how long it might be needed for.

[13] 28w • Ensure that a trained stoma professional gives specific information on the care and management of stomas to all patients considering surgery that might result in a stoma.

[14] 195w Colorectal cancer is the third leading cause of death from cancer in the United Kingdom, with a lifetime risk of about 2% in England and Wales, and its incidence is rising. 1 The outcome for people with colorectal cancer is improving, but the overall five year survival rates are still lower than 60%. 1 There is a need for greater accuracy in diagnosis and staging, more appropriate use of neoadjuvant and adjuvant therapies when treating potentially curable disease, and more effective use of resources when managing patients with advanced disease. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the diagnosis and management of people with colorectal cancer in secondary care. 2 Recommendations for referral from primary care for patients with suspected colorectal cancer are in the NICE clinical guideline 27. 3 Recommendations NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group's experience and opinion of what constitutes good practice. Evidence levels for the recommendations are in the full version of this article on bmj.com.

[15] 37w The recommendations in this section refer to people whose condition is being managed in secondary care. For recommendations for urgent referral from primary care for patients with suspected colorectal cancer, see the NICE clinical guideline 27. 3

[16] 21w • Advise the patient that more than one investigation may be necessary to confirm or exclude a diagnosis of colorectal cancer.

[17] 28w • Offer colonoscopy to patients without major comorbidity. If a lesion suspicious of cancer is detected, perform a biopsy unless contraindicated (for example, in patients with bleeding disorders).

[18] 10w Diagnosis and management of colorectal cancer: summary of NICE guidance

[19] 99w Berendse, 3 on behalf of the Guideline Development Group Staging of colorectal cancer Stage I-Primary tumour into but not through muscularis propria, and no metastases Stage II-Primary tumour grown through to serosa and peritoneal surface but no metastases Stage III-Any size of primary tumour with lymph node metastases Stage IV-Presence of distant metastatic disease bmj.com Previous articles in this series ЖHyperglycaemia in acute coronary syndromes (BMJ 2011;343:d6646) ЖRecognising and diagnosing autism in children and young people (BMJ 2011; 343:d6360) ЖManagement of stable angina (BMJ 2011;343:d4147) ЖAntenatal care for twin and triplet pregnancies (BMJ 2011;343:d5714) ЖManagement of hypertension (BMJ 2011;343:d4891)

[20] 29w • Do not offer short course preoperative radiotherapy or chemoradiotherapy to patients with operable rectal cancer at low risk of local recurrence, unless as part of a clinical trial.

[21] 21w • For patients with operable rectal cancer at moderate risk of local recurrence consider short course preoperative radiotherapy then immediate surgery.

[22] 33w • For patients whose tumours fall between moderate and high risk of local recurrence, consider preoperative chemoradiotherapy then surgery, but with an interval before surgery to allow the tumour to respond and shrink.

[23] 38w • For patients with operable rectal cancer at high risk of local recurrence offer preoperative chemoradiotherapy then surgery, but with an interval before surgery to allow the tumour to respond and shrink (rather than short course preoperative radiotherapy).

[24] 33w • For patients with locally advanced rectal cancer at high risk of local recurrence, offer preoperative chemoradiotherapy then surgery, but with an interval before surgery to allow the tumour to respond and shrink.

[25] 12w • Do not offer preoperative chemoradiotherapy solely to facilitate sphincter sparing surgery.

[26] 24w • Do not routinely offer preoperative chemotherapy alone for patients with locally advanced colon or rectal cancer unless as part of a clinical trial.

[27] 42w • If stenting is being considered for patients presenting with acute large bowel obstruction, offer CT scanning 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.

[28] 12w • Do not use contrast enema studies as the only imaging modality.

[29] 45w • The decision to insert a stent should be made by a consultant colorectal surgeon with an endoscopist or a radiologist, or both. Only healthcare professionals experienced in placing colonic stents and with access to fluoroscopic equipment and trained support staff should insert colonic stents.

[30] 25w • Consider placing a self expanding metallic stent to initially manage left sided complete or near complete colonic obstruction; do not dilate the tumour beforehand.

[31] 8w • Do not place self expanding metallic stents:

[32] 24w -In low rectal lesions or -To relieve right sided colonic obstruction or -If there is clinical or radiological evidence of colonic perforation or peritonitis.

[33] 24w • If a self expanding metallic stent is suitable try insertion urgently and no longer than 24 hours after patients present with colonic obstruction.

[34] 12w • For patients with locally excised, pathologically confirmed stage I colon cancer:

[35] 22w -The colorectal multidisciplinary team should consider offering further treatment, taking into account pathological characteristics of the lesion, imaging results, and previous treatments.

[36] 16w -Offer further treatment to patients whose tumour had involved resection margins of less than 1 mm.

[37] 31w • For patients with stage I rectal cancer a multidisciplinary team specialising in early rectal cancer 4 should decide which treatment to offer, taking into account previous treatments, such as radiotherapy.

[38] 18w • Prioritise treatment to control symptoms if at any point the patient has symptoms from the primary tumour.

[39] 38w • If both primary and metastatic tumours are considered resectable, site specific multidisciplinary teams (teams specialising in all relevant anatomical sites of the cancer) should consider initial systemic treatment followed by surgery, after full discussion with the patient.

[40] 21w Full details on the use of these therapies can be found in NICE guidance. [6][7][8][9][10] In patients with advanced colorectal cancer:

[41] 9w • Consider one of the following sequences of chemotherapy:

[42] 52w -FOLFOX (folinic acid plus fluorouracil plus oxaliplatin) as first line treatment then single agent irinotecan as second line treatment or -FOLFOX as first line treatment then FOLFIRI (folinic acid plus fluorouracil plus irinotecan) as second line treatment or -XELOX (capecitabine plus oxaliplatin) as first line treatment then FOLFIRI as second line treatment.

[43] 63w • Consider raltitrexed only for patients with advanced colorectal cancer who are intolerant to fluorouracil and folinic acid or for whom these drugs are not suitable. Note that at the time of publication (November 2011), irinotecan did not have UK marketing authorisation for use in second line combination therapy (FOLFIRI (folinic acid plus fluorouracil plus irinotecan)). Informed consent should be obtained and documented.

[44] 9w Ongoing care and support Follow-up after apparently curative resection

[45] 19w • Offer follow-up to all patients-to start at a clinic visit four to six weeks after potentially curative treatment.

[46] 5w • Offer regular surveillance with:

[47] 32w -At least two CT scans of the chest, abdomen, and pelvis in the first three years and -Regular serum carcinoembryonic antigen tests (at least every six months in the first three years).

[48] 45w • Offer a surveillance colonoscopy at one year after initial treatment. If this is normal consider further colonoscopy after five years, and thereafter as determined by cancer networks. Determine the timing of surveillance for patients with subsequent adenomas by the risk status of the adenoma.

[49] 16w • Start investigations again if there is any clinical, radiological, or biochemical suspicion of recurrent disease.

[50] 29w -The patient and the healthcare professional have discussed and agreed that the likely benefits no longer outweigh the risks of further tests or -The patient cannot tolerate further treatments.

[51] 46w • After any treatment, offer all patients specific information on managing the effects of the treatment on their bowel function. This could include information on incontinence, diarrhoea, difficulty emptying their bowels, bloating, excess flatus, diet, and where to go for help in the event of symptoms.

[52] 32w • Offer verbal and written information in a way that is clearly understood by patients and free of jargon. Include information about support organisations or internet resources recommended by the clinical team.