CLINICAL PRACTICE GUIDELINES The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Colon Cancer Jon D. Vogel, M.D. • Cagla Eskicioglu, M.D. • Martin R. Weiser, M.D. Daniel L. Feingold, M.D. • Scott R. Steele, M.D. Prepared by the Clinical Practice Guidelines Committee of The American Society of Colon and Rectal Surgeons he American Society of Colon and Rectal Surgeons STATEMENT OF THE PROBLEM is dedicated to ensuring high-quality patient care by advancing the science, prevention, and manage- In the United States, an estimated 96,000 and 38,000 new T cases of colon and rectal cancer will be diagnosed in 2017.1 ment of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is com- Colorectal cancer is the third most common cancer and posed of society members who are chosen because they cause of cancer death in both men and women in the Unit- have demonstrated expertise in the specialty of colon and ed States. The treatment of patients with colon cancer is rectal surgery. This committee was created to lead inter- largely guided by stage at presentation, emphasizing the national efforts in defining quality care for conditions re- importance of a comprehensive strategy of diagnosis, eval- lated to the colon, rectum, and anus. This is accompanied uation, and treatment. Surgery encompasses the primary by developing Clinical Practice Guidelines based on the form of treatment for colon cancer, whereas chemother- best available evidence. These guidelines are inclusive and apy is used most commonly in the adjuvant setting. The 5-year overall survival for patients with localized, regional, not prescriptive. Their purpose is to provide information 2 on which decisions can be made, rather than to dictate a and metastatic colon cancer is 91%, 72%, and 13%. specific form of treatment. These guidelines are intended The scope of this guideline is to address the issues re- for the use of all practitioners, health care workers, and lated to the evaluation and treatment of patients who have patients who desire information about the management been diagnosed with colon cancer. Matters pertinent to colon cancer screening and surveillance after colon cancer of the conditions addressed by the topics covered in these 3 4 guidelines. It should be recognized that these guidelines treatment, as well as rectal cancer, are addressed in sepa- should not be deemed inclusive of all proper methods of rate documents. care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regard- METHODOLOGY ing the propriety of any specific procedure must be made by the physician in light of all the circumstances presented This guideline is based on the previous parameter pub- by the individual patient. lished in 2012.5 An organized search of MEDLINE, EM- BASE, and the Cochrane Database of Collected Reviews Supplemental digital content is available for this article. Direct URL ci- was performed for the period of January 1, 1997 to April tations appear in the printed text, and links to the digital files are pro- 21, 2017. The complete search strategy is included as an vided in the HTML and PDF versions of this article on the journal’s Web appendix (http://links.lww.com/DCR/A436). In brief, a site (www.dcrjournal.com). total of 16,925 unique journal titles were identified. Initial Financial Disclosures: None reported. review of the search results resulted in exclusion of 11,204 titles based on either irrelevance of the title or the jour- Correspondence: Scott R. Steele, M.D., Chairman, Department of nal. Secondary review resulted in exclusion of 5,480 titles Colorectal Surgery Cleveland Clinic, Professor of Surgery Case Western considered irrelevant or outdated. A tertiary review of the Reserve University School of Medicine, 9500 Euclid Ave/A30, Cleveland, remaining 241 titles included assessment of the abstract or OH 44195. E-mail: [email protected] full-length article. This led to exclusion of an additional 30 titles for which similar but higher-level evidence was avail- Dis Colon Rectum 2017; 60: 999–1017 DOI: 10.1097/DCR.0000000000000926 able. The remaining 211 titles were considered for grading © The ASCRS 2017 of the recommendations. A directed search of references DISEASES OF THE COLON & RECTUM VOLUME 60: 10 (2017) 999 Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited. 1000 VOGEL ET AL: TREATMENT OF COLON CANCER embedded in the candidate publications was performed. formal evaluation, when possible, and consideration of Emphasis was placed on prospective trials, meta-analyses, genetics testing, because the results may impact surgical systematic reviews, and practice guidelines. Peer-reviewed decision making. Physical examination should include as- observational studies and retrospective studies were in- sessment for an abdominal mass lesion, adenopathy, or cluded when higher-quality evidence was insufficient. The surgical scars, all of which may influence diagnostic and final source material used was evaluated for the method- treatment-related decisions. Selective rather than routine ological quality, the evidence base was examined, and a use of preoperative laboratory testing such as complete treatment guideline was formulated by the subcommittee blood count, liver function tests, and coagulation studies for this guideline. A final grade of recommendation was are recommended for the evaluation of new patients with assigned using the Grades of Recommendation, Assess- colon cancer.8,9 Carcinoembryonic antigen levels should ment, Development, and Evaluation (GRADE) system typically be assessed before elective surgery for colon can- (Table 1).6 When agreement was incomplete regarding the cer to establish a baseline value and during the surveillance evidence base or treatment guideline, consensus from the period to monitor for signs of recurrence. A multivariate committee chair, vice chair, and 2 assigned reviewers de- analysis of over 130,000 patients included in the National termined the outcome. Members of the American Society Cancer Database recently indicated that preoperative CEA of Colon and Rectal Surgeons (ASCRS) practice guidelines is an independent predictor of overall survival in patients committee worked in joint production of these guide- with stage I to III colon cancer.10 Although higher CEA lines from inception to final publication. Recommenda- levels are generally associated with advanced cancer stage, tions formulated by the subcommittee were reviewed by conflicting evidence on the independent predictive value the entire Clinical Practice Guidelines Committee. Final of this test should be acknowledged.11–14 recommendations were approved by the ASCRS Clinical Guidelines Committee and ASCRS Executive Committee. 2. When possible, patients with presumed or proven co- In general, each ASCRS Clinical Practice Guideline is up- lon cancer should undergo a full colonic evaluation dated every 5 years. with histologic assessment of the colonic lesion before treatment. Grade of Recommendation: Strong recom- mendation based on low-quality evidence, 1C. RECOMMENDATIONS When possible, the histologic diagnosis of colon cancer Evaluation and Risk Assessment should be confirmed before elective surgical resection be- cause nonneoplastic processes such as diverticulitis or IBD 1. An assessment of disease-specific symptoms, past may be associated with the endoscopic or radiographic ap- medical and family history, physical examination, and pearance of colon cancer. Lesions concerning for malig- serum CEA level should typically be evaluated in pa- nancy, but without histologic confirmation (eg, possible tients with colon cancer. Grade of Recommendation: sampling error), that are not amenable to endoscopic re- Strong recommendation based on low-quality evi- moval warrant oncologic resection. When feasible, com- dence, 1C. plete evaluation of the colorectal mucosa is typically Sporadic, familial, and hereditary types of colon cancer advised before surgery to detect synchronous cancers, account for approximately 65%, 30%, and <5% of new which were recently reported to be present in 4% of 2400 cancers in the United States.7 Although often asymptom- patients with stages I to III sporadic colon cancer.15 Com- atic, colon cancer may also be heralded by symptoms of plete examination of the colorectal mucosa is also impor- fatigue, blood in the stool, abdominal pain, or obstructive tant to identify synchronous adenomas that are present in symptoms. These symptoms often correlate with more ad- 30% to 50% of patients.16,17 vanced stages of colon cancer and may be used to compli- In patients with colon cancer who have an endo- ment the information that is subsequently gained during scopically obstructing lesion or another reason for which the process of staging the cancer and planning treatment. complete colonoscopy was not performed, complete pre- Comorbid conditions should be assessed to help deter- operative mucosal examination may be accomplished via mine operative risk and to identify opportunities for med- a second attempt at conventional colonoscopy, CT colo- ical optimization before colon surgery. A careful history, nography, or colon capsule endoscopy. When performed including family history and colon cancer-specific history by expert endoscopists, 2 recent studies reported that re- can guide the surgeon to suspect hereditary cancer syn- peat colonoscopy resulted in