People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Consider daily aspirin, to be taken for more than 2 years, to reduce the risk of colorectal cancer in people with Lynch syndrome.
In January 2020 this was an off-label use of aspirin. See NICE's information on prescribing medicines.
NICE has produced a patient decision aid to support discussions about taking aspirin.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on prevention of colorectal cancer in people with Lynch syndrome.
Full details of the evidence and the committee's discussion are in evidence review A1: effectiveness of aspirin in the prevention of colorectal cancer in people with Lynch syndrome.
Provide people with colorectal cancer information about their treatment (both written and spoken) in a sensitive and timely manner throughout their care, tailored to their needs and circumstances. Make sure the information is relevant to them, based on the treatment they might have and the possible side effects. Also see the NICE guidelines on patient experience in adult NHS services and decision-making and mental capacity.
Give people information on all treatment options for colorectal cancer available to them, including:
surgery, radiotherapy, systemic anti-cancer therapy or palliative care
the potential benefits, risks, side effects and implications of treatments, for example, possible effects on bowel and sexual function (see also recommendation 1.6.2), quality of life and independence.
Advise people with colorectal cancer of possible reasons why their treatment plan might need to change during their care, including:
changes from laparoscopic to open surgery or curative to non-curative treatment, and why this change may be the most suitable option for them
the likelihood of having a stoma, why it might be necessary and for how long it might be needed.
If recovery protocols (such as 'enhanced recovery after surgery', ERAS) are used, explain to people with colorectal cancer what these involve and their value in improving their recovery after surgery.
Ensure that appropriate specialists discuss possible side effects with people who have had surgery for colorectal cancer, including:
altered bowel, urinary and sexual function
physical changes, including anal discharge or bleeding.
If relevant, have a trained stoma professional provide information on the care and management of stomas and on learning to live with a stoma.
Emphasise to people the importance of monitoring and managing side effects during non-surgical treatment to try to prevent permanent damage (for example, monitoring prolonged sensory symptoms after platinum-based chemotherapy treatment, which can be a sign that the dose needs to be reduced to minimise future permanent peripheral neuropathy).
Give people who have had treatments for colorectal cancer information about possible short-term, long-term, permanent and late side effects which can affect quality of life, including:
pain
altered bowel, urinary or sexual function
nerve damage and neuropathy
mental and emotional changes, including anxiety, depression, chemotherapy-related cognitive impairment, and changes to self-perception and social identity.
Prepare people for discharge after treatment for colorectal cancer by giving them advice on:
adapting physical activity to maintain their quality of life
diet, including advice on foods that can cause or contribute to bowel problems such as diarrhoea, flatulence, incontinence and difficulty in emptying the bowels
weight management, physical activity and healthy lifestyle choices (for example stopping smoking and reducing alcohol use)
how long their recovery might take
how, when and where to seek help if side effects become problematic.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on information for people with colorectal cancer.
Full details of the evidence and the committee's discussion are in evidence review E3: information needs of people prior, during and after treatment for colorectal cancer.
Offer one of the treatments shown in table 1 to people with early rectal cancer (cT1-T2, cN0, M0) after discussing the implications of each treatment and reaching a shared decision with the person about the best option.
| - | Transanal excision (TAE), including transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery (TEMS) | Endoscopic submucosal dissection (ESD) | Total mesorectal excision (TME) |
|---|---|---|---|
|
Type of procedure |
Endoscopic/Surgery |
Endoscopic |
Surgery |
|
Minimally invasive procedure |
Yes |
Yes |
Possible |
|
Resection of bowel (may have more impact on sexual and bowel function) |
No |
No |
Yes |
|
Stoma needed (a permanent or temporary opening in the abdomen for waste to pass through) |
No |
No |
Possible |
|
General anaesthetic needed (and the possibility of associated complications) |
Yes |
No, conscious sedation |
Yes |
|
Able to do a full thickness excision (better chance of removing cancerous cells and more accurate prediction of lymph node involvement) |
Yes |
No |
Yes |
|
Removal of lymph nodes (more accurate staging of the cancer so better chance of cure) |
No |
No |
Yes |
|
Conversion to more invasive surgery needed if complication |
Possible |
Possible |
Possible |
|
Further surgery needed depending on histology |
Possible |
Possible |
Usually no |
|
Usual hospital stay |
1 to 2 days |
1 to 2 days |
5 to 7 days |
|
External scarring |
No |
No |
Yes |
|
Possible complications include (in alphabetical order) |
Abdominal pain Bleeding Mild anal incontinence Perirectal abscess/sepsis and stricture (narrowing) Perforation Suture line dehiscence (wound reopening) Urinary retention |
Abdominal pain Bleeding Bloating Perforation |
Adhesions Anastomotic leak (leaking of bowel contents into the abdomen) Anastomotic stricture (narrowing at internal operation site) Bleeding Incisional hernia (hernia where the surgical incision was made) Injury to neighbouring structures Pelvic abscess Urinary retention |
Some of the potential complications shown in the table were identified from the evidence review, others based on committee's expertise.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on treatment for people with early rectal cancer.
Full details of the evidence and the committee's discussion are in evidence review C1: treatment for early rectal cancer.
Do not offer preoperative radiotherapy to people with early rectal cancer (cT1-T2 cN0, M0), unless as part of a clinical trial.
Offer preoperative radiotherapy or chemoradiotherapy to people with rectal cancer that is cT1-T2, cN1-N2, M0, or cT3-T4, any cN, M0.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on preoperative treatment for people with rectal cancer.
Full details of the evidence and the committee's discussion are in evidence review C1: treatment for early rectal cancer and evidence review C2: preoperative radiotherapy and chemoradiotherapy for rectal cancer.
Offer surgery to people with rectal cancer (cT1-T2, cN1-N2, M0, or cT3-T4, any cN, M0) who have a resectable tumour.
Inform people with a complete clinical and radiological response to neoadjuvant treatment who wish to defer surgery that there is a risk of recurrence, and there are no prognostic factors to guide selection for deferral of surgery. For those who choose to defer, encourage their participation in a clinical trial and ensure that data is collected via a national registry.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on surgery for people with rectal cancer.
Full details of the evidence and the committee's discussion are in evidence review C4: deferral of surgery in people having neoadjuvant therapy for rectal cancer.
Offer laparoscopic surgery for rectal cancer, in line with NICE's technology appraisal guidance on laparoscopic surgery for colorectal cancer.
Consider open surgery if clinically indicated, for example by locally advanced tumours, multiple previous abdominal operations or previous pelvic surgery.
Only consider robotic surgery within established programmes that have appropriate audited outcomes.
Only consider transanal total mesorectal excision (TME) surgery in the context of research in line with the NICE interventional procedures guidance on transanal total mesorectal excision for rectal cancer. [amended 2021]
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on surgical technique for people with rectal cancer.
Full details of the evidence and the committee's discussion are in evidence review C3: optimal surgical technique for rectal cancer.
Consider referring people with locally advanced primary or recurrent rectal cancer that might potentially need multi-visceral or beyond-TME surgery to a specialist centre to discuss exenterative surgery.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on locally advanced or recurrent rectal cancer.
Full details of the evidence and the committee's discussion are in evidence review C5: effectiveness of exenterative surgery for locally advanced or recurrent rectal cancer.
Hospitals performing major resection for rectal cancer should perform at least 10 of these operations each year.
Individual surgeons performing major resection for rectal cancer should perform at least 5 of these operations each year.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on surgical volumes for rectal cancer operations.
Full details of the evidence and the committee's discussion are in evidence review F1: surgical volumes and outcomes for rectal cancer.
Consider preoperative systemic anti-cancer therapy for people with cT4 colon cancer.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on preoperative treatment for people with colon cancer.
Full details of the evidence and the committee's discussion are in evidence review C7: preoperative chemotherapy for non-metastatic colon cancer.
For advice on laparoscopic surgery see NICE's technology appraisal guidance on laparoscopic surgery for colorectal cancer.
Patients with rectal cancer treated with long-course chemoradiotherapy are not covered by this recommendation.
For people with stage III colon cancer (pT1-4, pN1-2, M0), or stage III rectal cancer (pT1-4, pN1-2, M0) treated with short-course radiotherapy or no preoperative treatment, offer:
capecitabine in combination with oxaliplatin (CAPOX) for 3 months, or if this is not suitable
oxaliplatin in combination with 5-fluorouracil and folinic acid (FOLFOX) for 3 to 6 months, or
single-agent fluoropyrimidine (for example, capecitabine) for 6 months, in line with NICE technology appraisal guidance (see the NICE technology appraisal guidance on our topic page on colorectal cancer).
Base the choice on the person's histopathology (for example pT1-T3 and pN1, and pT4 and/or pN2), performance status, any comorbidities, age and personal preferences.
In January 2020, the use of some treatments was off label:
oxaliplatin in combination with capecitabine (though CAPOX is common in UK clinical practice)
capecitabine for 3 months duration of adjuvant treatment in people with colon cancer
CAPOX and FOLFOX in stage III rectal cancer.
See NICE's information on prescribing medicines.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on duration of adjuvant chemotherapy for people with colorectal cancer.
Full details of the evidence and the committee's discussion are in evidence review C8: optimal duration of adjuvant chemotherapy for colorectal cancer.
Consider stenting for people presenting with acute left-sided large bowel obstruction who are to be treated with palliative intent.
Offer either stenting or emergency surgery for people presenting with acute left-sided large bowel obstruction if potentially curative treatment is suitable for them.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on colonic stents in acute large bowel obstruction.
Full details of the evidence and the committee's discussion are in evidence review C9: effectiveness of stenting for acute large bowel obstruction.
Also see the NICE diagnostics guidance on molecular testing strategies for Lynch syndrome in people with colorectal cancer.
Test for RAS and BRAF V600E mutations in all people with metastatic colorectal cancer suitable for systemic anti-cancer treatment.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on molecular biomarkers to guide systemic anti-cancer therapy.
Full details of the evidence and the committee's discussion are in evidence review B1: use of molecular biomarkers to guide systemic therapy.
Consider surgical resection of the primary tumour for people with incurable metastatic colorectal cancer who are receiving systemic anti-cancer therapy and have an asymptomatic primary tumour. Discuss the implications of the treatment options with the person before making a shared decision. See table 2.
| - | Advantages | Disadvantages |
|---|---|---|
|
Resection of the asymptomatic primary tumour |
Possible improvement in overall survival rate (based on low quality evidence from research) Avoidance of primary tumour-related symptoms such as obstruction, perforation, bleeding and pain |
Around 5 in 100 people will have severe postoperative complications (based on moderate quality evidence from research) Systemic therapy still needed, and may be delayed if surgical complications occur |
|
No resection (systemic anti-cancer therapy only) |
Avoids surgery and the potential for postoperative complications |
Around 20 in 100 people will develop primary tumour-related symptoms such as obstruction, perforation, bleeding and pain that need surgery (based on low quality evidence from research) |
Advantages and disadvantages in table 2 are based on committee expertise unless otherwise indicated.
Quality of evidence (based on grading of recommendations, assessment, development and evaluations [GRADE]):
Moderate: true effect is probably close to the estimated effect.
Low: true effect might be markedly different from the estimated effect.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on asymptomatic primary tumour.
Full details of the evidence and the committee's discussion are in evidence review D1: surgery for asymptomatic primary tumour.
For advice on systemic anti-cancer therapy for people with metastatic cancer, see NICE technology appraisal guidance on our topic page on colorectal cancer.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on systemic anti-cancer therapy for people with metastatic colorectal cancer.
The point at which to use genomic biomarker-based therapy in solid tumour treatment pathways is uncertain. See the NICE topic page on genomic biomarker-based cancer treatments for guidance on specific treatments.
Consider resection, either simultaneous or sequential, after discussion by a multidisciplinary team with expertise in resection of disease in all involved sites.
Consider perioperative systemic anti-cancer therapy if liver resection is a suitable treatment.
Consider chemotherapy with local ablative techniques for people with colorectal liver metastases that are unsuitable for liver resection after discussion by a specialist multidisciplinary team.
Do not offer selective internal radiation therapy (SIRT) as first-line treatment for people with colorectal liver metastases that are unsuitable for local treatment. See the NICE interventional procedures guidance on selective internal radiation therapy for unresectable colorectal metastases in the liver, which recommends that SIRT should only be offered:
with special arrangements for clinical governance, consent, and audit or research to people who are chemotherapy intolerant or who have liver metastases that are refractory to chemotherapy
in the context of research to people who can have chemotherapy.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on metastatic colorectal cancer in the liver.
Full details of the evidence and the committee's discussion are in evidence review D2a: treatment for metastatic colorectal cancer in the liver amenable to treatment with curative intent and evidence review D2b: optimal combination and sequence of treatments in patients presenting with metastatic colorectal cancer in the liver not amenable to treatment with curative intent.
Consider metastasectomy, ablation or stereotactic body radiation therapy for people with lung metastases that are suitable for local treatment, after discussion by a multidisciplinary team that includes a thoracic surgeon and a specialist in non-surgical ablation.
Consider biopsy for people with a single lung lesion to exclude primary lung cancer.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on metastatic colorectal cancer in the lung.
Full details of the evidence and the committee's discussion are in evidence review D3: treatment for metastatic colorectal cancer in the lung amenable to local treatment.
For people with colorectal cancer metastases limited to the peritoneum:
offer systemic anti-cancer therapy and
within a multidisciplinary team, discuss referral to a nationally commissioned specialist centre to consider cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on metastatic colorectal cancer in the peritoneum.
Full details of the evidence and the committee's discussion are in evidence review D4: local and systemic treatments for metastatic colorectal cancer isolated in the peritoneum.
For people who have had potentially curative surgical treatment for non-metastatic colorectal cancer, offer follow-up for detection of local recurrence and distant metastases for the first 3 years. Follow-up should include serum carcinoembryonic antigen (CEA) and CT scan of the chest, abdomen and pelvis.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on follow-up for detection of local recurrence and distant metastases.
Full details of the evidence and the committee's discussion are in evidence review E1: follow-up to detect recurrence after treatment for non-metastatic colorectal cancer.
Give information on low anterior resection syndrome (LARS) to people who will potentially have sphincter-preserving surgery. Advise them to seek help from primary care if they think they have symptoms of LARS, such as:
increased frequency of stool
urgency with or without incontinence of stool
feeling of incomplete emptying
fragmentation of stool (passing small amounts little and often)
difficulty in differentiating between gas and stool.
Assess people with symptoms of LARS using a validated patient-administered questionnaire (for example, the Low Anterior Resection Syndrome score (LARS score), at the European Society of Coloproctology).
Offer people with bowel dysfunction treatment for associated symptoms in primary care (such as dietary management, laxatives, anti-bulking agents, anti-diarrhoeal agents, or anti-spasmodic agents). Seek advice from secondary care if the treatment is not successful.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on management of low anterior resection syndrome.
Full details of the evidence and the committee's discussion are in evidence review E2: optimal management of low anterior resection syndrome.
This section defines terms that have been used in a specific way for this guideline. For general definitions, please see the NICE glossary.
Beyond total mesorectal excision (TME) surgery is when the tumour extends beyond what is achievable to resect by TME and needs more extensive surgery to achieve clear margins.
Major resection for rectal cancer means a surgical operation when part or all of the rectum is removed, including anterior resection and abdominoperineal resection.
Recovery protocols, such as 'enhanced recovery after surgery' (ERAS), are perioperative care pathways designed to promote early recovery for patients undergoing major surgery by optimising the person's health before surgery and maintaining health and functioning after surgery.
Social identity is about changes to people's concept of themselves as a result of either their cancer, or the long-term side effects from treatment. For example, it could cover changes from being a previously fit person to someone who has physical or mental health problems, from being someone with the expectation of years to live to someone with a limited life expectancy, or the change from being a carer to becoming cared for.
This guideline uses the tumour, node, metastasis (TNM) classification developed by the Union for Interventional Cancer Control (UICC) to describe the stage of the cancer. Please refer to The TNM Classification of Malignant Tumours, 8th Edition for further information. In this guideline early rectal cancer is defined as cT1-2, cN0, M0. cTNM refers to clinical classification based on evidence acquired before treatment, for example imaging, physical examination and endoscopy. pTNM refers to pathological classification based on histopathology.