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Version 3.2013, 11/26/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN®.®
NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
NCCN.org
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ) ®
Colon Cancer
Version 3.2013
Continue
IMPORTANT NOTE REGARDING
LEUCOVORIN SHORTAGE,
PLEASE SEE MS-13
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
NCCN Colon Cancer Panel Members
Summary of the Guidelines Updates
Pedunculated polyp (adenoma [tubular, tubulovillous, or villous])
with invasive cancer (COL-1)
Sessile polyp with
invasive cancer (COL-1)
Colon cancer appropriate for resection (COL-2)
Pathologic Stage, Adjuvant Therapy, and Surveillance (COL-3)
Recurrence and Workup (COL-9)
Principles of Pathologic Review (COL-A)
Chemotherapy for Advanced or Metastatic Disease (COL-C)
Principles of Risk Assessment for Stage II Disease (COL-D)
Principles of Adjuvant Therapy (COL-E)
Principles of Radiation Therapy (COL-F)
Principles of Survivorship (COL-G)
Staging (ST-1)
·
·
··
(adenoma [tubular, tubulovillous, or villous])
Suspected or proven metastatic adenocarcinoma (COL-5)
Principles of Surgery (COL-B)
Clinical Presentations and Primary Treatment:
Clinical Trials:
Categories of Evidence andConsensus:NCCN
All recommendationsare category 2A unless otherwisespecified.
See
believes thatthe best management for any cancer patient is in a clinical trial.Participation in clinical trials isespecially encouraged.
NCCN
To find clinical trials online at NCCNMember Institutions, click here:nccn.org/clinical_trials/physician.html .
NCCN Categories of Evidenceand Consensus
NCCN Guidelines Version 3.2013 Table of ContentsColon Cancer
The NCCN Guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment.
Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical
circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network (NCCN ) makes no representations or
warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN
Guidelines are copyrighted by National Comprehensive Cancer Network . All rights reserved. The NCCN Guidelines and the illustrations herein may not
be reproduced in any form without the express written permission of NCCN. ©2012.
®
® ®
®
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®
NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
UPDATES
Summary of changes in the 2.2013 version of the Colon Guidelines from the 1.2013 version include:
NCCN Guidelines Version 3.2013 UpdatesColon Cancer
COL-11
COL-C 1 of 9, COL-C 2 of 9, COL-C 3 of 9
COL-C 8 of 9
COL-C 9 of 9
COL-D
MS-1
· Unresectable metachronous metastases, previous adjuvant FOLFOX within the past 12 months: Primary treatment regimens made consistentwith therapy after first progression regimens on page COL-C 1 of 9. The following regimens added: FOLFIRI ± ziv-aflibercept, Irinotecan ±bevacizumab, Irinotecan ± ziv-aflibercept, (Cetuximab or panitumumab) (KRAS WT gene only) + irinotecan.
Regorafenib added as a treatment option in therapy after first, second, or third progression, depending on previous lines of therapy. Bestsupportive care and clinical trial also listed as alternate options to regorafenib.
Regorafenib regimen added: regorafenib 160 mg PO daily days 1-21, repeat every 28 days.
Reference for regorafenib added: Grothey A, Sobrero AF, Siena S, et al. Results of a phase III randomized, double-blind, placebo-controlled,multicenter trial (CORRECT) of regorafenib plus best supportive care (BSC) versus placebo plus BSC in patients (pts) with metastaticcolorectal cancer (mCRC) who have progressed after standard therapies [abstract]. J Clin Oncol 2012;30 (suppl 4):LBA385.
Bullet 4 modified:
stageII MSI-H patients may have a good prognosis and do not benefit from 5-FU adjuvant therapy.
The Discussion section updated to reflect the changes in the algorithm.
·
·
·
· Testing for MMR proteins should be considered for all patients <50 years of age or with stage II disease. The panel recommends that MMR protein testing be performed for all patients younger than 50 years with colon cancer, based on an increased likelihood of Lynch syndrome in this population. MMR testing should also be considered for all patients with stage II disease, because
·
Summary of changes in the 3.2013 version of the Colon Guidelines from the 1.2013 version include:
COL-C 3 of 9· FOLFOX and CapeOx added as treatment options in therapy after second progression for patients treated previously with irinotecan-based
chemotherapy.
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
UPDATES
COL-C 7 of 9
COL-C 9 of 9
http://meeting.ascopubs.org/cgi/content/abstract/30/15_suppl/3505COL-D
COL-E
COL-F
·
·
·
·
·
·
·
·
The following regimen was added:FOLFIRI + ziv-aflibercept12
Irinotecan 180 mg/m IV over 30-90 minutes, day 1Leucovorin 400 mg/m IV infusion to match duration of irinotecan infusion, day 15-FU 400 mg/m IV bolus day 1, then 1200 mg/m /day x 2 days (total 2400 mg/m over 46-48 hours)† continuous infusionZiv-aflibercept 4 mg/kg IVRepeat every 2 weeks
Reference 12 is new to the page: Allegra CJ, Lakomy R, Tabernero J, et al. Effects of prior bevacizumab (B) use on outcomes from the VELOUR study: A phase III study of aflibercept (Afl) and FOLFIRI in patients (pts) with metastatic colorectal cancer (mCRC) after failureof an oxaliplatin regimen [abstract]. J Clin Oncol 2012;30 (suppl.):3505. Available at:
Bullet 2, sub-bullet 2 modified to be consistent with COL-3: “Poor prognostic features (eg, poorly differentiated histology [exclusive of those that are MSI-H], lymphatic/vascular invasion, bowel obstruction, perineural invasion, localized perforation or close,indeterminate or positive margins)”
Bullet 4 modified to be consistent with COL-3: “Testing for MMR proteins should be considered for all patients <50 years of age.”
Bullet 3 added: A survival benefit has not been demonstrated for the addition of oxaliplatin to 5-FU/leucovorin in stage II colon cancer.Bullet 4 added: A benefit for the addition of oxaliplatin to 5-FU/leucovorin in patients age 70 and older has not been proven.Reference “5” is new to the page.
Bullet 3 modified: , conformal external beam radiation should be routinely usedand intensity-modulated radiation therapy (IMRT) should be reserved only for unique clinical situations including
re-irradiation of previously treated patients with recurrent disease.
2
2
2 2 2
or withstage II disease
If radiation therapy is to be used for T4 non-metastaticdisease radiotherapy
Summary of changes in the 1.2013 version of the Colon Guidelines from the 3.2012 version include:
NCCN Guidelines Version 3.2013 UpdatesColon Cancer
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Suspected or proven
metastatic adenocarcinoma
SeePathologicStage,AdjuvantTherapy, and
Surveillance(COL-3)
·
·
·
·
Pathology review
Colonoscopy
CBC, platelets,
chemistry profile,CEA
bdominal/
pelvic
PET-CT scan is not
routinely indicated
e
· Chest/a
i
CTh
Resectable,
nonobstructing
See management of suspected or proven metastatic synchronousadenocarcinoma (COL-5)
CLINICAL
PRESENTATIONa,b
WORKUP FINDINGS SURGERY
Colon cancer
appropriate for resection (non-
metastatic)
Resectable,obstructing
Locally
unresectable
or medicallyinoperable
Colectomy with en
bloc removal of
regional lymph nodes
g
One-stage colectomy
with en bloc removal of
regional lymph nodes
or Resection with diversion
or Stentor Diversion
g
Colectomy with en
bloc removal of
regional lymph nodes
g
See Chemotherapyfor Advanced or
Metastatic Disease(COL-C)
a
b
Small bowel and appendiceal adenocarcinoma may be treated with systemic chemotherapy according to the NCCN Guidelines for Colon Ca
.
All patients with colon cancer should be counseled for family history and considered for risk assessment. Patients with suspected hereditary non-polyposis colon cancer (HNPCC), familial adenomatous polyposis (FAP), and attenuated FAP, see the
- Colon cancer appropriate for resection, pathological stage, and lymph node evaluation.e
g
i
PET-CT does not supplant a contrast-enhanced diagnostic CT scan.
ncer. Peritonealmesothelioma and other extrapleural mesotheliomas may be treated with systemic therapy along NCCN Guidelines for Pleural Mesothelioma, as outlined on pageMPM-A
NCCN Guidelines for Colorectal Cancer Screening
See Principles of Pathologic Review (COL-A)
.
See Principles of Surgery (COL-B 1 of 3).hCT should be with IV and oral contrast. Consider abd/pelvic MRI with MRI contrast plus a non-contrast chest CT if either CT of abd/pelvis is inadequate or if patient has
a contraindication to CT with IV contrast.
COL-2
NCCN Guidelines Version 3.2013Colon Cancer
y g p y pp py g p , , g
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Suspected or
proven metastatic
synchronous
adenocarcinoma
(Any T, any N, M1)
CLINICAL
PRESENTATION
WORKUP FINDINGS
·
·
·
·
·
·
·
Colonoscopy
Chest/abdominal/pelvic CT
CBC, platelets, chemistry profileCEA
Needle biopsy, if clinically indicated
z
e
· Determination of tumor KRAS gene
status (if KRAS non-mutated,
consider BRAF testing)
PET-CT scan only if potentially
surgically curable M1 disease
Multidisciplinary team evaluation,including a surgeon experienced in
the resection of hepatobiliary and
lung metastases
See Treatmentand AdjuvantTherapy (COL-6)
See PrimaryTreatment (COL-8)
Synchronous
liver only and/or
lung only
metastases
Synchronous
abdominal/peritoneal
metastases
Resectableg
e
g
z
- KRAS and BRAF Mutation Testing.
CT should be with IV contrast. Consider MRI with IV contrast if CT is inadequate.
See Principles of Pathologic Review (COL-A 4 of 5)
See Principles of Surgery (COL-B 2 of 3).
See Treatmentand AdjuvantTherapy (COL-7)
Unresectable
(potentially
convertible or
unconvertible)
g
COL-5
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
Colon resection
or
Diverting colostomy
or
Bypass of impendingobstruction
or
Stenting
g
FINDINGS PRIMARY TREATMENT
Nonobstructing
Obstructed
or imminentobstruction
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Synchronousabdominal/
peritoneal
metastasesee
See Chemotherapy for Advanced or Metastatic
Disease (COL-C)
See Chemotherapy for
Advanced or MetastaticDisease (COL-C)
g .
Aggressive cytoreductive debulking and/or intraperitoneal chemotherapy are not recommended outside the setting of a clinical trial.eeSee Principles of Surgery (COL-B 2 of 3)
COL-8
NCCN Guidelines Version 3.2013Colon Cancer
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
WORKUPRECURRENCE
Serial
CEA
elevation
Negative
findings
Positivefindings
·
·
·
·
Physical exam
Colonoscopy
Chest/abdominal/
pelvic CT
Consider PET-CT
scan
·
·
Consider PET-CT scan
Re-evaluate chest/
abdominal/pelvic CT
in 3 mo
Negativefindings
Positive
findings
Documented
metachronous
metastases
by CT, MRI,
and/or biopsy
ff,gg
See treatment for
Documentedmetachronous
metastases, below
See treatment for
Documented
metachronous
metastases, below
g
gg
ff Determination of tumor KRAS .(if KRAS non-mutated, consider BRAF testing) - KRAS and BRAF Mutation Testing.
Patients should be evaluated by a multidisciplinary team including surgical consultation for potentially resectable patients.
See Principles of Surgery (COL-B 2 of 3).
See Principles of Pathologic Review (COL-A 4 of 5)
COL-9
Resectable
g
See Primary
Treatment (COL-10)
See Primary
Treatment (COL-11)
Resectableg
Unresectable
Consider
PET-CTscan
Unresectable
(potentially
convertible or unconvertible)
g
NCCN Guidelines Version 3.2013Colon Cancer
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Neoadjuvant
chemotherapy
( )
(2-3 mo)
See COL-4
PRIMARY TREATMENT
Previous
chemotherapy
Resectionaa
No previous
chemotherapy
or
Resectionaa
Neoadjuvant
chemotherapy
( )
(2-3 mo)
See COL-C
Resectionaa
or
Resectionaa
Observation (preferred for
previous oxaliplatin-based therapy)
or Active chemotherapy regimen
( )
hh
See COL-C
No growth on
neoadjuvant
chemotherapy
Growth on
neoadjuvant
chemotherapy
Active chemotherapy
regimen ( )hh See COL-Cor Observation
Repeat neoadjuvant
therapyor FOLFOX
hh
aaHepatic artery infusion ± systemic 5-FU/leucovorin (category 2B) is also an option at institutions with experience in both the surgical and medical oncologic aspects of this procedure.
Perioperative therapy should be considered for up to a total of 6 months.hh
COL-10
RESECTABLE
METACHRONOUS METASTASES
Active chemotherapy
regimen ( )hh See COL-Cor Observation
Repeat neoadjuvant
therapyor FOLFOXor Observation
hh
FOLFOX/CapeOx preferred
ADJUVANT TREATMENT
No growth on
neoadjuvant
chemotherapy
Growth on
neoadjuvant
chemotherapy
NCCN Guidelines Version 3.2013Colon Cancer
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
e
hh
- KRAS and BRAF Mutation Testing.
Hepatic artery infusion ± systemic 5-FU/leucovorin (category 2B) is also an option at institutions with experience in both the surgical and medical oncologic aspects of this procedure.
Perioperative therapy should be considered for up to a
s progressed on first-line therapy.
aa
See Principles of Pathologic Review (COL-A 4 of 5)
See Principles of Surgery (COL-B 2 of 3).g
iitotal of 6 months.
Patients with a V600E BRAF mutation appear to have a poorer prognosis. Limited available data suggest a lack of antitumor activity from anti-EGFR monoclonalantibodies in the presence of a V600E mutation when used after a patient ha
PRIMARY TREATMENT
·
·
·
Previous adjuvant FOLFOX
>12 months
Previous 5-FU/LV or
capecitabine
No previous chemotherapy
Active chemotherapy
regimen ( )See COL-C
Converted to
resectable
Remainsunresectable
Active
chemotherapyregimen
( )or Observation
hh
See COL-CResectionaa
Active chemotherapyregimen ( )See COL-C
Re-evaluate for
conversion to
resectable every
2 mo if conversion
to resectability is
a reasonable goal
g
COL-11
UNRESECTABLE
METACHRONOUS METASTASES
· Previous adjuvant FOLFOX
within past 12 months
FOLFIRI ± bevacizumab
or
or FOLFIRI ± ziv-afliberceptor Irinotecan ± bevacizumabor Irinotecan ± ziv-aflibercept
FOLFIRI + (cetuximab or panitumumab)
(KRAS WT gene only)or
(Cetuximab or
panitumumab) (KRAS WT
gene only) + irinotecan
e,ii
e,ii
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
PRINCIPLES OF SURGERY (1 of 3)
See Criteria for Resectability of Metastases andLocoregional Therapies Within Surgery on COL-B 2 of 3
ColectomyLymphadenectomy
Management of patients with carrier status of kConsider more extensive colectomy for patients with a strong family history of colon cancer or young age (<50 y).
·
·
·
>
>
>
>
Lymph nodes at the origin of feeding vessel should be identified for pathologic exam.Clinically positive lymph nodes outside the field of resection that are considered suspicious should be biopsied or removed, if possible.Positive nodes left behind indicate an incomplete (R2) resection.
> A minimum of 12 lymph nodes need to be examined to establish N stage.1
· Laparoscopic-assisted colectomy may be considered based upon the following criteria:The surgeon has experience performing laparoscopically assisted colorectal operations.There is no disease in the rectum or prohibitive abdominal adhesions.There is no locally advanced disease.It is not indicated for acute bowel obstruction or perforation from cancer.Thorough abdominal exploration is required.
nown or clinically suspected HNPCC
2
3,4
5
>
>
>
>
>
> Consider preoperative marking of small lesions.
See NCCN Guidelines for Colorectal Cancer Screening
Resection needs to be complete to be considered curative.
See footnotes on COL-B 3 of 3
COL-B1 of 3
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NCCN G id li I dNCCN G id li V i 3 2013
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
CONTINUUM OF CARE - CHEMOTHERAPY FOR ADVANCED OR METASTATIC DISEASE: (PAGE 1 of 9)1
Patient
appropriate
for
intensive
therapy2
FOLFOX ±bevacizumabor CapeOX ±
bevacizumab
3
4
5,6
FOLFOX
± panitumumab(KRAS wild-type
[WT] gene only)
3
6,7
8,9
or
FOLFIRI ± bevacizumab
or
5,10
or
FOLFIRI ± ziv-afliberceptor Irinotecan ± bevacizumabor Irinotecan ± ziv-aflibercept
FOLFIRI + (cetuximab or
panitumumab)
(KRAS WT gene only)
or (Cetuximab or
panitumumab) (KRAS
WT gene only) + irinotecan
11
11
6,
8
6,
8
10
10
12-15
12-15
10
Regorafenibor Clinical trialor Best supportive care16
(Cetuximab or panitumumab)
(KRAS WT gene only) +
irinotecan;
for patients not able to toleratecombination, consider single agent
(cetuximab or panitumumab)
(KRAS WT gene only)
6,
8
6,12-15
8
12-15
10
or Regorafenib (KRAS mutant only)
COL-C1 of 9
See footnotes on COL-C 5 of 9
Initial Therapy Therapy After First Progression
Therapy After Second Progression
Additional options on
throughCOL-C 2 of 9 COL-C 3 of 9
For patients not appropriate for intensive therapy, see COL-C 4 of 9
Therapy After Third Progression
Regorafenib (if not
given previously)
or Clinical trialor Best supportive care16
NCCN Guidelines Version 3.2013Colon Cancer
NCCN Guidelines IndexNCCN Guidelines Version 3 2013
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
COL-C2 of 9
See footnotes on COL-C 5 of 9
CONTINUUM OF CARE - CHEMOTHERAPY FOR ADVANCED OR METASTATIC DISEASE: (PAGE 2 of 9)1
Patient
appropriate
for
intensive
therapy2
FOLFIRI +bevacizumab
105,6
FOLFOX
or
3,5
4,5
12-15
10
± bevacizumabor
CapeOX ± bevacizumab
(Cetuximab or
panitumumab)
(KRAS WT gene only) +
irinotecan; for patients
not able to tolerate
combination, consider
single agent (cetuximab or panitumumab)
(KRAS WT gene only)
6,
8
6,12-15
8
FOLFOX3
4or
CapeOX
FOLFIRI ±
cetuximab or
panitumumab
(KRAS WT gene
only)
10
6,7
8,9
or
Initial Therapy
Additional options onthroughCOL-C 1 of 9 COL-C 3 of 9
For patients not appropriate for intensive therapy, see COL-C 4 of 9
Therapy After First Progression
Therapy After Second Progression
Therapy After Third Progression
(Cetuximab or panitumumab)
(KRAS WT gene only) +
irinotecan;
for patients not able to tolerate
combination, consider single agent
(cetuximab or panitumumab)
(KRAS WT gene only)
6,
8
6,12-15
8
12-15
10
or Regorafenib (KRAS mutant only)
Regorafenib (if not
given previously)or Clinical trialor Best supportive care16
NCCN Guidelines Version 3.2013Colon Cancer
NCCN Guidelines IndexNCCN Guidelines Version 3 2013
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
COL-C3 of 9
See footnotes on COL-C 5 of 9
CONTINUUM OF CARE - CHEMOTHERAPY FOR ADVANCED OR METASTATIC DISEASE: (PAGE 3 of 9)1
Additional options onthroughCOL-C 1 of 9 COL-C 2 of 9
For patients not appropriate for intensive therapy, see COL-C 4 of 9
NCCN Guidelines Version 3.2013Colon Cancer
Patient
appropriate
for
intensive
therapy2
Irinotecan + oxaliplatin ±
bevacizumab
or
± bevacizumab
or
Irinotecan ± ziv-afliberceptor FOLFIRI ± bevacizumabor FOLFIRI ± ziv-aflibercept
10
10
10
10
Irinotecan
11
11
5-FU/leucovorinor Capecitabine± bevacizumab
17
5,6,19
18
FOLFOXIRI(category 2B)
20
Irinotecan10
or
FOLFOX ±
bevacizumab
or
CapeOX ±
bevacizumab
3,5
4,5
or
Initial Therapy Therapy After First Progression Therapy After Second Progression Therapy After ThirdProgression
(Cetuximab or panitumumab)
(KRAS WT gene only) +
irinotecan;
for patients not able to tolerate
combination, consider single agent
(cetuximab or panitumumab)
(KRAS WT gene only)
6,
8
6,12-15
8
12-15
10
or Regorafenib (KRAS mutant only)
Regorafenib (if not
given previously)or Clinical trialor
Best supportive care16
(Cetuximab or panitumumab)
(KRAS WT gene only) +
irinotecan;
for patients not able to tolerate
combination, consider single agent
(cetuximab or panitumumab)(KRAS WT gene only)
6,
8
6,12-15
8
12-15
10
or Regorafenib (KRAS mutant only)
Regorafenib (if not
given previously)or Clinical trialor Best supportive care16
FOLFOX or CapeOX3 4
NCCN Guidelines IndexNCCN Guidelines Version 3 2013
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
CONTINUUM OF CARE - CHEMOTHERAPY FOR ADVANCED OR METASTATIC DISEASE: (PAGE 4 of 9)1
Initial Therapy Therapy After First Progression
See footnotes on COL-C 5 of 9
COL-C4 of 9
Patient not
appropriatefor
intensive
therapy2
Infusional 5-FU + leucovorin or
Capecitabine ± bevacizumab Improvement in
functional status
No improvement in
functional status
Consider initial therapy as21COL-C 1 of 9 COL-C 3 of 9through
Best supportive careSee NCCN Guidelines for Palliative Care
Cetuximab (KRAS WT geneonly) (category 2B)8,9
or
Panitumumab (KRAS WT gene
only) (category 2B)8,9
or
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NCCN Guidelines IndexColon Cancer Table of Contents
NCCN Guidelines Version 3.2013C l C
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Colon Cancer Table of ContentsDiscussion
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
PRINCIPLES OF RADIATION THERAPY
··
·
Radiation therapy fields should include the tumor bed, which should be defined by preoperative radiological imaging and/or surgical clips.Radiation doses should be 45-50 Gy in 25-28 fractions.
Consider boost for close or positive margins.Small bowel dose should be limited to 45 Gy.5-FU-based chemotherapy should be delivered concurrently with radiation.
Intraoperative radiation therapy (IORT), if available, should be considered for patients with T4 or recurrent cancers as an additional boost.
Preoperative radiation therapy with concurrent 5-FU-based chemotherapy is a consideration for these patients to aid resectability. If IORT isnot available, additional 10-20 Gy external beam radiation and/or brachytherapy could be considered to a limited volume.
:>
>
>
·
·
·
If radiation therapy is to be used, conformal external beam radiation should be routinely used and intensity-modulated radiation therapy
(IMRT) should be reserved only for unique clinical situations including re-irradiation of previously treated patients with recurrent disease.
Some institutions use arterially directed embolization in select patients with chemotherapy-
resistant/refractory disease, without obvious systemic disease, and with predominant hepatic metastases (category 3).
In patients with a limited number of liver or lung metastases, radiotherapy can be considered in highly selected cases or in the setting of a
clinical trial. Radiotherapy should not be used in the place of surgical resection. Radiotherapy should be delivered in a highly conformal
manner. The techniques can include 3-D conformal radiation therapy, IMRT, or stereotactic body radiation therapy (SBRT) (category 3).
using Yttrium-90 microspheres
COL-F
Colon Cancer
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
NCCN Guidelines Version 3.2013Colon Cancer
rather than discrete. Principles to consider at initiation of therapy include
pre-planned strategies for altering therapy for patients in both the
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presence and absence of disease progression, including plans for
adjusting therapy for patients who experience certain toxicities.
Recommended initial therapy options for advanced or metastatic
disease depend on whether the patient is appropriate for intensive
therapy. The more intensive initial therapy options include FOLFOX,
FOLFIRI, CapeOx, and FOLFOXIRI (category 2B). Addition of a biologic
agent (eg, bevacizumab, cetuximab, panitumumab) is either
recommended or listed as an option in combination with some of these
regimens, depending on available data. Chemotherapy options for
patients with progressive disease depend on the choice of initial
therapy. The panel endorses the concept that treating patients in a
clinical trial has priority over standard treatment regimens.
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NCCN Guidelines IndexColon Cancer Table of Contents
Discussion
NCCN Guidelines Version 3.2013Colon Cancer
475. Meyerhardt JA, Heseltine D, Niedzwiecki D, et al. Impact of physical activity on cancer recurrence and survival in patients with stageIII colon cancer: findings from CALGB 89803. J Clin Oncol
2006;24:3535-3541. Available at:http://www.ncbi.nlm.nih.gov/pubmed/16822843 .
476. Meyerhardt JA, Niedzwiecki D, Hollis D, et al. Association of
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y , , ,dietary patterns with cancer recurrence and survival in patients withstage III colon cancer. JAMA 2007;298:754-764. Available at:http://www.ncbi.nlm.nih.gov/pubmed/17699009 .
477. Meyerhardt JA, Giovannucci EL, Ogino S, et al. Physical activityand male colorectal cancer survival. Arch Intern Med 2009;169:2102-2108. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20008694 .
478. Kushi LH, Byers T, Doyle C, et al. American Cancer SocietyGuidelines on Nutrition and Physical Activity for cancer prevention:reducing the risk of cancer with healthy food choices and physicalactivity. CA Cancer J Clin 2006;56:254-281; quiz 313-254. Available at:http://www.ncbi.nlm.nih.gov/pubmed/17005596 .
479. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient toCancer Survivor: Lost in Transition. Committee on Cancer Survivorship:Improving Care and Quality of Life, Institute of Medicine and NationalResearch Council: National Academy of Sciences; 2006. Available at:http://www.nap.edu/catalog/11468.html .