Guideline sources The following summarized guidelines for the evaluation and management of colon cancer (CRC) are prepared by our editorial team based on guidelines from the European Society of Medical Oncology (ESMO 2023; 2020), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES/ASCRS 2023), the American Society of Clinical Oncology (ASCO 2023; 2022; 2019), the American Society of Colon and Rectal Surgeons (ASCRS 2022; 2015; 2014), the College of American Pathologists (CAP/AMP/FCC 2022), the American Gastroenterological Association (AGA 2021), the American College of Gastroenterology (ACG 2021; 2019; 2015), the U.S. Preventive Services Task Force (USPSTF 2021; 2016), the Hereditary Haemorrhagic Telangiectasia Working Group (HHT-WG 2020), the US Multi-Society Task Force on Colorectal Cancer (USMSTF 2020; 2017; 2016), the British Society of Gastroenterology (BSG 2019; 2018), the World Society of Emergency Surgery (WSES 2018), the American College of Surgeons (ACS 2018), and the American Society for Gastrointestinal Endoscopy (ASGE 2014). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 21 22 23 24 25 26 27 https://web.pathway.md/diseases/rec9r57boQNGLwXBu 1/6 6/23/23, 3:26 AM Colon cancer Pathway Guidelines 1. Screening and diagnosis Indications for screening, general population, aged 45-49 years: As per ACG 2021 guidelines, consider obtaining screening for colorectal cancer in 45-49 years old average-risk individuals to reduce the incidence of advanced adenoma, colorectal cancer, and mortality from colorectal cancer. C As per USPSTF 2021 guidelines, obtain screening for colorectal cancer in 45-49 years old individuals. B As per USMSTF 2017 guidelines, consider obtaining screening for colorectal cancer starting at the age of 45 in African Americans. C Indications for screening, general population, aged 50-75 years: As per ACG 2021 guidelines, obtain screening for colorectal cancer in 50-75 years old average- risk individuals to reduce the incidence of advanced adenoma, colorectal cancer, and mortality from colorectal cancer. B As per USPSTF 2021 guidelines, obtain screening for colorectal cancer in all 50-75 years old individuals. A Updated evidence: NordICC In healthy men and women 55 to 64 years of age who had previously not undergone screening, colonoscopy screening was superior to usual care with respect to colorectal cancer at 10 years. Michael Bretthauer et al. N Engl J Med. 2022 Oct 27. As per USMSTF 2017 guidelines, obtain screening for colorectal cancer starting at the age of 50 in average-risk individuals. A Consider discontinuing colorectal cancer screening at the age of 75 years or when life expectancy is < 10 years in individuals with up-to-date screening and negative prior screening tests, particularly colonoscopy. B Indications for screening, general population, aged 76-85 years: As per ACG 2021 guidelines, consider individualizing the decision to continue colorectal cancer screening beyond the age of 75 years. C As per USPSTF 2021 guidelines, offer screening for colorectal cancer selectively in 76-85 years old individuals, taking into account the patient's overall health, prior screening history, and preferences. B As per ACS 2018 guidelines, continue colorectal cancer screening through the age of 75 years in average-risk individuals in good health with a life expectancy of > 10 years continue. B Show 2 more https://web.pathway.md/diseases/rec9r57boQNGLwXBu 2/6 6/23/23, 3:26 AM Colon cancer Pathway As per USMSTF 2017 guidelines, consider continuing colorectal cancer screening up to age 85 in individuals without prior screening, depending on consideration of their age and comorbidities. C Indications for screening, high-risk individuals, family history: As per ACG 2021 guidelines, consider obtaining screening for colorectal cancer (with a colonoscopy, every 5 years) starting at the age of 40 or 10 years before the youngest affected relative, whichever is earlier, in individuals with colorectal cancer or advanced polyp in 1 first- degree relative at age < 60 years or colorectal cancer or advanced polyp in 2 first-degree relatives at any age. C Show 3 more As per USMSTF 2017 guidelines, consider obtaining screening for colorectal cancer (with colonoscopy every 5 years beginning 10 years younger than the age at which the youngest first- degree relative was diagnosed or age 40, whichever is earlier) in individuals with 1 first-degree relative with colorectal cancer or a documented advanced adenoma diagnosed at age < 60 years or with 2 first-degree relatives with colorectal cancer and/or documented advanced adenomas. C Show 3 more Indications for screening (high-risk individuals, hereditary cancer syndromes): obtain screening for colorectal cancer in patients at risk for or affected with Lynch syndrome, B adenomatous polyposis syndromes, B Peutz-Jeghers syndrome, B juvenile polyposis syndrome, B or Cowden syndrome. B Show 4 more Indications for screening, high-risk individuals, IBD: As per ACG 2019 guidelines, consider obtaining colonoscopic screening and surveillance to identify neoplasia in patients with ulcerative colitis of any extent beyond the rectum. C Show 10 more As per BSG 2019 guidelines, obtain ileocolonoscopy 8 years after symptom onset to screen for neoplasia, determine disease extent, and decide on the frequency of ongoing surveillance in patients with IBD with colonic involvement. B As per ASCRS 2014 guidelines, obtain endoscopic surveillance in patients with long-standing ulcerative colitis. B Show 3 more Indications for screening, high-risk individuals, PSC: As per ACG 2019 guidelines, obtain screening colonoscopy at the time of diagnosis of ulcerative colitis in patients with PSC and ulcerative colitis, followed by surveillance colonoscopy annually thereafter. E As per BSG 2019 guidelines: Obtain annual colonoscopic surveillance from the time of diagnosis of colitis in patients with PSC with coexistent colonic IBD. A https://web.pathway.md/diseases/rec9r57boQNGLwXBu 3/6 6/23/23, 3:26 AM Colon cancer Pathway Consider obtaining less frequent 5-year colonoscopies, or earlier in the advent of new symptoms, in patients with PSC without IBD. C Indications for screening (high-risk individuals, HHT): obtain screening for colorectal cancer (with colonoscopy) in patients with SMAD4-hemorrhagic telangiectasia (genetically proven or suspected). B Choice of screening tests, primary choice: As per ACG 2021 guidelines, obtain colonoscopy and FIT as the primary screening modalities for colorectal cancer screening. B As per ESMO 2020 guidelines, obtain a complete colonoscopy every 10 years B as the modality of choice for colorectal cancer screening in 50-74 years old B average-risk individuals. B As per USMSTF 2020 guidelines: Obtain repeat colonoscopy in 10 years in patients with normal, high-quality colonoscopy. A Obtain repeat colonoscopy in 10 years in patients with 20 hyperplastic polyps < 10 mm in size in the rectum or sigmoid colon removed at a high-quality examination. B As per USMSTF 2017 guidelines: Consider offering sequential screening tests, multiple screening options, or risk-stratified screening as reasonable approaches for colorectal cancer screening. C Obtain colonoscopy every 10 years or an annual FIT as first-tier options for colorectal cancer screening in average-risk individuals. B Choice of screening tests, alternative choices: As per ACG 2021 guidelines: Consider obtaining flexible sigmoidoscopy (every 5-10 years), multitarget stool DNA test (every 3 years), CT colonography (every 5 years), or colon capsule endoscopy (every 5 years) as alternative screening modalities in individuals unable or unwilling to undergo colonoscopy or FIT. C Avoid obtaining septin-9 for colorectal cancer screening. D As per ESMO 2020 guidelines, consider obtaining flexible sigmoidoscopy every 5-10 years as an alternative modality in individuals refusing colonoscopy. C Combine this method with a yearly FOBT to reduce the risk of a right colon tumor. C Show 2 more As per USMSTF 2017 guidelines, obtain CT colonography every 5 years, FIT-fecal DNA every 3 years, B or flexible sigmoidoscopy every 5-10 years as alternative options. A Show 2 more Indications for testing (lower GI bleeding): obtain colonoscopy or an evaluation sufficient to determine the resolution of bleeding in < 50 years old adult patients with colorectal bleeding symptoms (hematochezia, unexplained iron deficiency anemia, melena with a negative upper endoscopy) to determine a bleeding cause, initiate treatment, and complete follow-up. B https://web.pathway.md/diseases/rec9r57boQNGLwXBu 4/6 6/23/23, 3:26 AM Colon cancer Pathway Indications for testing (chronic diarrhea): obtain colonoscopy to exclude colorectal cancer in patients with altered bowel habits with or without rectal bleeding. A Indications for testing (chronic constipation): Obtain colonoscopy to exclude organic disease before surgical treatment in patients with chronic constipation presenting with rectal bleeding, heme-positive stool, iron deficiency anemia, or weight loss. A Obtain colonoscopy in > 50 years old patients presenting with chronic constipation if they have not previously had colorectal cancer screening. A 2. Classification and risk stratification Staging: use the AJCC TNM system for staging CRC. B 3. Diagnostic investigations History and physical examination: As per ASCRS 2022 guidelines, elicit cancer-specific history, including disease-specific symptoms and past medical and family history, perform a physical examination, and obtain a perioperative risk assessment in patients with CRC. B As per ESMO 2020 guidelines, perform a comprehensive physical examination before deciding on the definitive treatment approach in patients with CRC. B Laboratory tests: As per ASCRS 2022 guidelines, obtain routine laboratory tests, including serum CEA level, in patients with CRC. B As per ESMO 2020 guidelines, obtain laboratory tests, including CBCs, biochemistry, and serum CEA level, before deciding on the definitive treatment approach in patients with CRC. B Imaging for staging, CT/MRI: As per ESMO 2023 guidelines: Obtain contrast-enhanced CT of the chest, abdomen, and pelvis for staging colorectal cancer. B Obtain liver MRI to characterize non-typical liver lesions on CT or when liver metastases seem resectable or potentially resectable. B As per ASCRS 2022 guidelines, obtain CT of the chest, abdomen, and pelvis with oral and IV contrast or non-contrast CT of the chest and MRI of the abdomen for CRC staging. B As per ESMO 2020 guidelines: Obtain CT of the chest, abdomen, and pelvis with IV contrast as the preferred imaging modality for the evaluation of the extent of colorectal cancer. B Obtain contrast-enhanced MRI for the evaluation of the relationship of locally advanced tumors with surrounding structures or in defining ambiguous liver lesions. B https://web.pathway.md/diseases/rec9r57boQNGLwXBu 5/6 6/23/23, 3:26 AM Colon cancer Pathway Imaging for staging, PET: As per ESMO 2023 guidelines, consider obtaining a FDG-PET, particularly in patients with increased tumor markers without evidence of metastatic disease, or to define the extent of metastatic disease on potentially resectable metastases. C As per ASCRS 2022 guidelines, do not obtain PET/CT for routine CRC staging. Consider obtaining PET/CT for surgical decision-making in patients with stage IV disease. D Evaluation in emergency settings: recognize that the clinical presentation of colonic obstruction and perforation is variable, and laboratory tests are not specific. Obtain further diagnostic tools whenever available. B Show 4 more 4. Diagnostic procedures Diagnostic colonoscopy: Perform a total colonoscopy for diagnostic confirmation of CRC and to rule out synchronous tumors in the absence of indications for urgent tumor resection. Combine limited left-sided colonoscopy with CT colonoscopy as an alternative if a full colonoscopy is not possible. A Perform a complete colonoscopy within 3-6 months following tumor resection if not performed before or during the surgical procedure. B Biopsy and histopathology (general principles): establish the histologic diagnosis of invasive adenocarcinoma before colectomy and evaluate the entire colorectal mucosa for synchronous pathology when possible. B Biopsy and histopathology, technical considerations: As per ESMO 2023 guidelines: Perform fixation with 10% neutral buffered formalin (4% formaldehyde) for 6 hours and 48 hours for biomarker testing. B Review all available tumor specimens by the primary pathologist and enrich samples by macro-dissection to maximize tumor cell content (> 20%) before DNA extraction. B As per ESMO 2020 guidelines, include the following in the standard surgical/pathological report of CRC: specimen description and surgical procedure tumor site and size macroscopic tumor perforation histological type and grade extension into the bowel wall and adjacent organs distance of cancer from resected margins (proximal, distal, and radial) presence or absence of tumor deposits lymphovascular and/or perineural invasion tumor budding, site, and number of removed and involved regional lymph nodes https://web.pathway.md/diseases/rec9r57boQNGLwXBu 6/6