Clinical practice guidelines in oncology

The panel believes that a multidisciplinary approach is necessary for managing colorectal cancer. The panel endorses the concept that treating patients in a clinical trial has priority over standard or accepted therapy. The recommended surgical procedure for resectable colon cancer is an en bloc resection and adequate lymphadenectomy. Adequate pathologic assessment of the resected lymph nodes is important, with a goal of evaluating at least 12 nodes. Adjuvant therapy with FOLFOX (category 1, preferred), FLOX (category 1), CapeOx (category 1), 5-FU/LV (category 2A), or capecitabine (category 2A) is recommended by the panel for patients with stage III disease. Adjuvant therapy for patients with high-risk stage II disease is also an option; the panel recommends 5-FU/LV with or without oxaliplatin (FOLFOX or FLOX) or capecitabine with or without oxaliplatin (category 2A for all treatment options). Patients with metastatic disease in the liver or lung should be considered for surgical resection if they are candidates for surgery and if all original sites of disease are amenable to resection (R0) and/or ablation. Preoperative chemotherapy can be considered as initial therapy in patients with synchronous or metachronous resectable metastatic disease. When a response to chemotherapy would likely convert a patient from an unresectable to a resectable state (i.e., conversion therapy), this therapy should be initiated. Adjuvant chemotherapy should be considered after resection of liver or lung metastases. The recommended posttreatment surveillance program includes serial CEA determinations and periodic chest, abdominal, and pelvic CT scans, colonoscopic evaluations, and a survivorship plan to manage long-term side effects of treatment, facilitate disease prevention, and promote a healthy lifestyle. Recommendations for patients with disseminated metastatic disease represent a continuum of care in which lines of treatment are blurred rather than discrete. Principles to consider at initiation of therapy include preplanned strategies for altering therapy for patients in both the 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 (e.g., 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.