Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Colon Cancer Version 3.2015 NCCN.org NCCN Guidelines for Patients® available at www.nccn.org/patients Continue Version 3.2015, 06/18/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Alexandre Ferreira on 10/25/2015 6:11:16 AM. For personal use only. Not approved for distribution. Copyright © 2015 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Version 3.2015 Panel Members NCCN Guidelines Index Colon Cancer Table of Contents Colon Cancer Discussion * Al B. Benson, III, MD/Chair † Axel Grothey, MD † Eric Rohren, MD, PhD ф Robert H. Lurie Comprehensive Cancer Mayo Clinic Cancer Center The University of Texas Center of Northwestern University MD Anderson Cancer Center Howard S. Hochster, MD * Alan P. Venook, MD/Vice-Chair † ‡ Yale Cancer Center/Smilow Cancer Hospital David P. Ryan, MD † UCSF Helen Diller Family Massachusetts General Hospital Comprehensive Cancer Center Steven Hunt, MD ¶ Cancer Center Siteman Cancer Center at Barnes- Tanios Bekaii-Saab, MD † Jewish Hospital and Washington * Leonard Saltz, MD † ‡ Þ The Ohio State University Comprehensive University School of Medicine Memorial Sloan Kettering Cancer Center Cancer Center - James Cancer Hospital and Solove Research Institute Ahmed Kamel, MD ф Sunil Sharma, MD † University of Alabama at Birmingham Huntsman Cancer Institute Emily Chan, MD, PhD † Comprehensive Cancer Center at the University of Utah Vanderbilt-Ingram Cancer Center Natalie Kirilcuk, MD ¶ David Shibata, MD ¶ Yi-Jen Chen, MD, PhD § Stanford Cancer Institute Moffitt Cancer Center City of Hope Comprehensive Cancer Center Lucille A. Leong, MD † John M. Skibber, MD ¶ City of Hope Comprehensive The University of Texas Harry S. Cooper, MD ≠ Cancer Center MD Anderson Cancer Center Fox Chase Cancer Center Edward Lin, MD † Constantinos T. Sofocleous, MD, PhD ф Paul F. Engstrom, MD † Fred Hutchinson Cancer Research Center/ Memorial Sloan Kettering Cancer Center Fox Chase Cancer Center Seattle Cancer Care Alliance Elena M. Stoffel, MD ¤ Peter C. Enzinger, MD † Wells A. Messersmith, MD † University of Michigan Dana-Farber/Brigham and Women’s University of Colorado Cancer Center Comprehensive Cancer Center Cancer Center Mary F. Mulcahy, MD ‡ Eden Stotsky-Himelfarb, RN ¥ Moon J. Fenton, MD, PhD † Robert H. Lurie Comprehensive Cancer The Sidney Kimmel Comprehensive St. Jude Children’s Research Hospital/ Center of Northwestern University Cancer Center at Johns Hopkins University of Tenessee Health Science Center James D. Murphy, MD, MS § Christopher G. Willett, MD § UC San Diego Moores Cancer Center Duke Cancer Institute Charles S. Fuchs, MD, MPH † Dana-Farber/Brigham and Women’s Steven Nurkin, MD, MS ¶ NCCN Cancer Center Roswell Park Cancer Institute Deborah Freedman-Cass, PhD Kristina M. Gregory, RN, MSN, OCN Jean L. Grem, MD † Sarika Trikha, PharmD Fred and Pamela Buffett Cancer Center at The Nebraska Medical Center † Medical oncology Þ Internal medicine § Radiotherapy/Radiation ф Diagnostic/Interventional Continue oncology radiology ¶ Surgery/Surgical oncology ¤ Gastroenterology ≠ Pathology ¥ Patient advocate NCCN Guidelines Panel Disclosures ‡ Hematology/Hematology *Writing Committee Member oncology Version 3.2015, 06/18/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Alexandre Ferreira on 10/25/2015 6:11:16 AM. For personal use only. Not approved for distribution. Copyright © 2015 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Version 3.2015 Table of Contents NCCN Guidelines Index Colon Cancer Table of Contents Colon Cancer Discussion NCCN Colon Cancer Panel Members Clinical Trials: NCCN believes that Summary of the Guidelines Updates the best management for any cancer Clinical Presentations and Primary Treatment: patient is in a clinical trial. • Pedunculated polyp (adenoma) with invasive cancer (COL-1) Participation in clinical trials is especially encouraged. • Sessile polyp (adenoma) with invasive cancer (COL-1) To find clinical trials online at NCCN • Colon cancer appropriate for resection (COL-2) Member Institutions, click here: • Suspected or proven metastatic synchronous adenocarcinoma (COL-5) nccn.org/clinical_trials/physician.html. Pathologic Stage, Adjuvant Therapy, and Surveillance (COL-3) NCCN Categories of Evidence and Recurrence and Workup (COL-9) Consensus: All recommendations are category 2A unless otherwise specified. Principles of Pathologic Review (COL-A) Principles of Surgery (COL-B) See NCCN Categories of Evidence and Consensus. 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) 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. ©2015. Version 3.2015, 06/18/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Alexandre Ferreira on 10/25/2015 6:11:16 AM. For personal use only. Not approved for distribution. Copyright © 2015 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Version 3.2015 Updates NCCN Guidelines Index Colon Cancer Table of Contents Colon Cancer Discussion Updates in Version 3.2015 of the NCCN Guidelines for Colon Cancer from Version 2.2015 include: COL-11 • Previous adjuvant FOLFOX/CapeOx within past 12 months: bevacizumab listed as preferred in combination with FOLFIRI or irinotecan. Ramucirumab added as an option in combination with FOLFIRI or irinotecan. • Footnote “ll” added: “Bevacizumab is the preferred anti-angiogenic agent based on toxicity and cost.” COL-C 1 of 9 and COL-C 3 OF 9 • Therapy after First progression: bevacizumab listed as preferred in combination with FOLFIRI or irinotecan. Ramucirumab added as an option in combination with FOLFIRI or irinotecan. COL-C 5 of 9 • Footnote “12” added: “Bevacizumab is the preferred anti-angiogenic agent based on toxicity and cost.” COL-C 7 of 9 and COL-C 9 of 9 • The regimen and reference added for FOLFIRI + ramucirumab. MS-1 • The discussion section was updated to reflect the changes in the algorithm. Updates in Version 2.2015 of the NCCN Guidelines for Colon Cancer from Version 1.2015 include: MS-1 • The discussion section was updated to reflect the changes in the algorithm. Updates in Version 1.2015 of the NCCN Guidelines for Colon Cancer from Version 3.2014 include: COL-1 • Clinical presentation modified: “Pedunculated or sessile polyp (adenoma[tubular, tubulovillous, or villous]) with invasive cancer.” • Workup, bullet 3 modified: “Marking of cancerous polyp site (at time of colonoscopy or within 2 weeksif deemed necessary by the surgeon).” COL-2 • For patients with resectable, obstructing colon cancer, the option of stent was added in selected cases. COL-5 • Workup, bullet 5 modified: “Determination of tumor RAS (KRAS/NRAS) gene status for RAS (KRAS exon 2 and non-exon 2, and NRAS) and BRAF (if RAS non-mutated, consider BRAF testing).” (also applies to footnote “jj” on COL-9) • Workup, bullet 7 modified: “Consider PET-CT scan only if potentially surgically curable M1 disease in selected cases.” • Footnote “aa” added with reference, Moulton CA, Gu CS, Law CH, et al. Effect of PET before liver resection on surgical management for colorectal adenocarcinoma metastases: a randomized clinical trial. JAMA 2014;311:1863-1869. (also applies to COL-9) • The finding “Synchronous unresectable metastases of other sites” was added with link to the treatment recommendations for “Chemotherapy for Advanced or Metastatic Disease (COL-C 1 of 9).” • Footnote “bb” added: “Consider colon resection only if imminent risk of obstruction or significant bleeding.” COL-6 • Colectomy, with “Synchronous or staged colectomy with liver or lung resection.” • FOLFOX + cetuximab added as a treatment option with the following footnote “ff”: “There are conflicting data regarding the use of FOLFOX + cetuximab in patients who have potentially resectable liver metastases.” (also applies to COL-7) • Footnote “hh” added: “Total duration of perioperative chemotherapy should not exceed 6 months.” (also applies to COL-7) Version 3.2015, 06/18/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form