What are the guideline sources, guidelines and references for Rectal cancer ?
Guideline sources The following summarized guidelines for the evaluation and management of rectal cancer (RC) are prepared by our editorial team based on guidelines from the European Society of Medical Oncology (ESMO 2023; 2020; 2017), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES/ASCRS 2023), the American Society of Clinical Oncology (ASCO 2023), the American Society of Colon and Rectal Surgeons (ASCRS 2022; 2020; 2015; 2014), the College of American Pathologists (CAP/AMP/FCC 2022), the U.S. Preventive Services Task Force (USPSTF 2021; 2016), the American Society for Radiation Oncology (ASTRO 2021), the American College of Gastroenterology (ACG 2021; 2019; 2015), the American Gastroenterological Association (AGA 2021), 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 American College of Surgeons (ACS 2018), the World Society of Emergency Surgery (WSES 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 20 21 22 23 24 25 26 27 Calculator Calculator Calculator https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 1/17 6/24/23, 2:57 PM Rectal cancer Pathway Calculator Calculator Calculator Eastern Cooperative Oncology G Fong clinical risk score for hepat Karnofsky Guidelines 1. Screening and diagnosis Indications for screening, general population, aged 45-49 years: As per ACG 2021 guidelines, consider obtaining screening for coloRC in 45-49 years old average-risk individuals to reduce the incidence of advanced adenoma, coloRC, and mortality from coloRC. C As per USPSTF 2021 guidelines, obtain screening for coloRC in 45-49 years old individuals. B As per USMSTF 2017 guidelines, consider obtaining screening for coloRC 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 coloRC in 50-75 years old average-risk individuals to reduce the incidence of advanced adenoma, coloRC, and mortality from coloRC. B As per USPSTF 2021 guidelines, obtain screening for coloRC in all 50-75 years old individuals. A As per USMSTF 2017 guidelines, obtain screening for coloRC starting at the age of 50 in average-risk individuals. A Consider discontinuing coloRC 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 coloRC screening beyond the age of 75 years. C As per USPSTF 2021 guidelines, offer screening for coloRC 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 coloRC 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 As per USMSTF 2017 guidelines, consider continuing coloRC 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: https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 2/17 6/24/23, 2:57 PM Rectal cancer Pathway As per ACG 2021 guidelines, consider obtaining screening for coloRC (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 coloRC or advanced polyp in 1 first-degree relative at age < 60 years or coloRC or advanced polyp in 2 first-degree relatives at any age. C Show 3 more As per USMSTF 2017 guidelines, consider obtaining screening for coloRC (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 coloRC or a documented advanced adenoma diagnosed at age < 60 years or with 2 first- degree relatives with coloRC and/or documented advanced adenomas. C Show 3 more Indications for screening (high-risk individuals, hereditary cancer syndromes): obtain screening for coloRC 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 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 coloRC (with colonoscopy) in patients with SMAD4-hemorrhagic telangiectasia (genetically proven or suspected). B Choice of screening tests, primary choice: https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 3/17 6/24/23, 2:57 PM Rectal cancer Pathway As per ACG 2021 guidelines, obtain colonoscopy and FIT as the primary screening modalities for coloRC screening. B As per ESMO 2020 guidelines, obtain a complete colonoscopy every 10 years B as the modality of choice for coloRC 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 coloRC screening. C Obtain colonoscopy every 10 years or an annual FIT as first-tier options for coloRC 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 coloRC 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 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 coloRC screening. A Indications for testing (chronic diarrhea): obtain colonoscopy to exclude coloRC in patients with altered bowel habits with or without rectal bleeding. A https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 4/17 6/24/23, 2:57 PM Rectal cancer Pathway 2. Classification and risk stratification Staging: use the AJCC TNM system for staging RC. B 3. Diagnostic investigations History and physical examination: As per ASCRS 2020 guidelines: Elicit cancer-specific history, including disease-specific symptoms, associated symptoms, and family history, and obtain perioperative risk assessment in patients with RC. B Perform a complete physical examination, including an assessment of the distance of the distal extent of the tumor from the anal verge and the tumor's relation to the sphincter complex. B As per ESMO 2017 guidelines, elicit a history and perform a physical examination, including a DRE, to define functional status and assess for metastases in patients with RC. B Laboratory tests: As per ASCRS 2020 guidelines, obtain routine laboratory tests, including serum CEA level, as indicated. B As per ESMO 2017 guidelines, obtain a CBC, liver and renal function tests, and serum CEA in the evaluation of patients with RC. B Imaging for staging, pelvic MRI: As per ASTRO 2021 guidelines, obtain pelvic MRI with a RC protocol for preoperative clinical T and N staging in patients with RC. B As per ASCRS 2020 guidelines, obtain RC protocol pelvic MRI for locoregional clinical staging. B As per ESMO 2017 guidelines: Obtain pelvic MRI to define locoregional clinical staging. Detect extramural vascular invasion and determine the T substage and distance to the circumferential resection margin to predict the risks of synchronous/metachronous distant metastases, select patients for the respective preoperative management, and define the extent of surgery. B Obtain chest and abdomen CT to assess for the presence of metastases in patients with RC. B Imaging for staging (EUS): consider obtaining endorectal ultrasound for differentiating between early T stages (T1 versus T2) or when MRI is contraindicated. B Imaging for staging, thoracoabdominal CT/MRI: As per ESMO 2023 guidelines: Obtain contrast-enhanced CT of the chest, abdomen, and pelvis for staging coloRC. B Obtain liver MRI to characterize non-typical liver lesions on CT or when liver metastases seem resectable or potentially resectable. B https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 5/17 6/24/23, 2:57 PM Rectal cancer Pathway 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 coloRC. 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 Imaging for staging (PET): consider obtaining a FDG-positron emission tomography, 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 Evaluation in emergency settings: perform a DRE for lower RC. Obtain further diagnostic tools whenever available. B Show 4 more 4. Diagnostic procedures Diagnostic colonoscopy: perform rigid rectoscopy and preoperative colonoscopy to the cecal pole, or virtual colonoscopy in case of obstruction, to exclude synchronous colonic tumors in patients with RC. Perform completion colonoscopy within 6 months of surgery if not performed preoperatively. B Biopsy and histopathology (general principles): establish the histological diagnosis of invasive adenocarcinoma before elective treatment and obtain a full colonic evaluation so the treatment plan can address synchronous pathology, as needed. 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 ASCRS 2020 guidelines, acquire accurate, detailed, and consistent RC pathology reporting to determine prognosis, facilitate treatment planning, and improve quality assessment. B As per ESMO 2017 guidelines, examine at least 12 regional lymph nodes. Document proximal, distal, and circumferential margins in millimeters (separately for tumor and involved lymph nodes). B Molecular testing, dMMR/MSI status: As per ESMO 2023 guidelines, obtain testing for MMR status in all patients at the time of metastatic coloRC diagnosis. A Show 2 more As per FCC/AMP/CAP 2022 guidelines, obtain MMR-immunohistochemistry and/or MSI testing by PCR to detect DNA MMR defects in patients with coloRC suitable for immune checkpoint https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 6/17 6/24/23, 2:57 PM Rectal cancer Pathway inhibitor therapy. Consider obtaining a validated MSI testing by next-generation sequencing assay to detect DNA MMR defects. A Show 5 more Molecular testing (specific gene mutations): obtain testing for KRAS, NRAS exon 2, 3, 4, and BRAF mutations in all patients at the time of metastatic coloRC diagnosis. A Show 4 more Molecular testing (DPD deficiency): obtain DPD genotyping or phenotyping before initiating fluoropyrimidine-based adjuvant therapy. B 5. Medical management Management of nonmetastatic disease, neoadjuvant therapy, indications: As per ASTRO 2021 guidelines, offer neoadjuvant radiotherapy in patients with stage II-III RC. A Consider omitting neoadjuvant radiotherapy after discussion with a multidisciplinary team in patients with stage II RC at a lower risk of locoregional recurrence. B Show 3 more As per ASCRS 2020 guidelines, offer neoadjuvant therapy in patients with clinical stage II-III RC. Tailor the neoadjuvant regimen to the individual patient after multidisciplinary team discussion. A As per WSES 2018 guidelines, offer a multimodal approach with neoadjuvant chemoradiotherapy in patients with locally advanced RC. A As per ESMO 2017 guidelines, decide on offering neoadjuvant therapy in patients with locally advanced RC based on preoperative, MRI-predicted circumferential resection margin ( 1 mm), extramural vascular invasion, and more advanced T3 substages (T3c/T3d), which define the risk of both local recurrence and/or synchronous and subsequent metastatic disease. E Management of nonmetastatic disease, neoadjuvant therapy, regimens: As per ASTRO 2021 guidelines, offer conventional fractionation from 5,000-5,040 cGy in 25-28 fractions with concurrent chemotherapy in patients with RC receiving neoadjuvant chemoradiotherapy. A Show 6 more As per ESMO 2017 guidelines, decide on a preoperative approach in patients with locally advanced RC based on a multidisciplinary team decision regarding the risk of a circumferential resection margin at total mesorectal excision surgery. A Show 3 more Management of nonmetastatic disease (neoadjuvant therapy, assessment of response): assess pathologic response to neoadjuvant therapy at the time of radical resection. B Consider obtaining restaging evaluation after neoadjuvant therapy in patients with locally advanced RC. B Management of nonmetastatic disease, neoadjuvant therapy, interval to surgery: As per ASTRO 2021 guidelines: https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 7/17 6/24/23, 2:57 PM Rectal cancer Pathway Ensure an interval of 6 A to 11 weeks from the end of neoadjuvant chemoradiotherapy to surgery if no further neoadjuvant chemotherapy is planned. B Ensure an interval of either 3 days or 4-8 weeks from the end of neoadjuvant short-course radiotherapy to surgery if no further neoadjuvant chemotherapy is planned. B As per ESMO 2017 guidelines, perform immediate surgery within 7 days from the end of neoadjuvant treatment, and ideally within 0-3 days if the patient is 75 years (< 10 days from the first radiation fraction), in case of short-course preoperative radiotherapy in patients with resectable RC not requiring downstaging. A Management of nonmetastatic disease, local excision: As per ASTRO 2021 guidelines, consider performing local excision after neoadjuvant chemoradiotherapy for organ preservation after a multidisciplinary discussion in patients with cT2N0 RC meeting all of the following: permanent colostomy or inadequate bowel continence is expected after total mesorectal excision declines total mesorectal excision ypT1 disease and R0 margins upon local excision agrees to undergo close follow-up by a multidisciplinary team. C As per ASCRS 2020 guidelines, consider performing local excision in carefully selected patients with cT1N0 RC without high-risk features. B As per ESMO 2017 guidelines: Consider performing local excisional procedures (such as transanal endoscopic microsurgery) as a single modality in patients with early RC (cT1N0 without adverse features like G3, V1, L1). B Consider offering local radiotherapy (brachytherapy or contact therapy - Papillon technique) as an alternative to local surgery, alone or combined with chemoradiotherapy. C Management of nonmetastatic disease, radical resection: As per ASCRS 2020 guidelines, perform radical resection in patients with an apparent complete clinical response to neoadjuvant therapy. Consider offering a watch-and-wait management approach in highly selected patients in the context of a protocolized setting. B Show 16 more As per ESMO 2017 guidelines: Perform radical total mesorectal excision in patients with more advanced tumors up to and including cT2c/T3a/b because of higher risks of mesorectal lymph node involvement and recurrence. Perform total mesorectal excision as the standard of care, implying that all of the mesorectal fat, including all lymph nodes, are meticulously excised. B Obtain histopathological examination of mesorectal resections with a photographic record of the surgical specimen and assessment of total mesorectal excision quality. B Management of nonmetastatic disease, adjuvant therapy, indications: As per ASTRO 2021 guidelines: https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 8/17 6/24/23, 2:57 PM Rectal cancer Pathway Consider offering nonoperative management after a multidisciplinary discussion in patients with a complete clinical response to neoadjuvant treatment and meeting all of the following: permanent colostomy or inadequate bowel continence is expected after total mesorectal excision declines total mesorectal excision agrees to undergo close follow-up by a multidisciplinary team. C Consider offering concurrent chemoradiotherapy with or without induction or consolidation chemotherapy in patients with RC eligible for nonoperative management. C As per ASCRS 2020 guidelines: Offer adjuvant chemotherapy, starting within 8 weeks of radical resection, in patients with clinical or pathologic stage II-III RC if preoperative systemic chemotherapy has not been administered. B Consider offering adjuvant radiotherapy in selected patients with high-risk, pathologic stage II- III RC, particularly if neoadjuvant therapy has not been administered. B As per ESMO 2017 guidelines, consider offering postoperative chemoradiotherapy selectively in patients with unexpected adverse histopathological features after primary surgery (such as positive circumferential resection margin, perforation in the tumor area, incomplete mesorectal resection, extranodal deposits, or nodal deposits with extracapsular spread close to the mesorectal fascia) or in other cases with a high risk of local recurrence if preoperative radiotherapy has not been administered. B Management of nonmetastatic disease (adjuvant therapy, technical considerations): offer conventional fractionation from 5,000-5,400 cGy in 25-30 fractions with concurrent chemotherapy in patients with RC planned for nonoperative management or local excision after radiotherapy. B Show 6 more Management of metastatic disease, general principles: As per ESMO 2023 guidelines, discuss treatment approaches for all patients with metastatic coloRC within a multidisciplinary team of experts (especially in local treatment) meeting regularly to review oligometastatic disease cases. B As per ASCRS 2020 guidelines, arrange a multidisciplinary team tumor board discussion for the management of patients with RC. B Show 2 more Management of metastatic disease (surgical resection): do not perform resection of an asymptomatic primary tumor as a standard of care in patients with unresectable metastatic disease. D Management of metastatic disease, systemic therapy, first line: As per ASCO 2023 guidelines, offer doublet (FOLFOX or FOLFIRI) backbone chemotherapy as first-line therapy in patients with initially unresectable microsatellite stable or proficient MMR metastatic coloRC. B Show 3 more https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 9/17 6/24/23, 2:57 PM Rectal cancer Pathway As per ESMO 2023 guidelines, initiate biological therapy in combination with chemotherapy in the first-line treatment unless contraindicated. A Show 13 more As per ASCRS 2020 guidelines, consider offering chemotherapy as first-line therapy in patients with asymptomatic, unresectable metastatic RC. B Management of metastatic disease (systemic therapy, maintenance): consider offering maintenance treatment with fluoropyrimidine and bevacizumab in non-progressive patients (after at least 4 months of treatment) after first-line therapy with chemotherapy based on oxaliplatin- bevacizumab. B Show 3 more Management of metastatic disease, systemic therapy, second line: As per ASCO 2023 guidelines, offer encorafenib plus cetuximab in patients with previously treated BRAF V600E-mutant metastatic coloRC progressing after at least one previous line of therapy. B As per ESMO 2023 guidelines, offer irinotecan-based or monotherapy as second-line therapy in patients treated with first-line oxaliplatin-based therapy, and oxaliplatin-based therapy (FOLFOX or CAPOX) in patients treated with first-line irinotecan-based therapy. B Show 6 more Management of metastatic disease (systemic therapy, subsequent lines): consider reintroducing the initial induction therapy after second-line therapy as long as the patient did not progress during the induction course of first-line chemotherapy. C Show 8 more Management of metastatic disease (palliative interventions): consider offering a palliative intervention in patients with symptomatic, unresectable metastatic RC. B Management of metastases (general principles): Consider offering local treatment as a primary or metastasis-specific treatment to halt further dissemination and/or following systemic therapy as a consolidation treatment to delay or pause further treatment. C Obtain frequent (generally every 8-12 weeks) radiological re-evaluations of the potential applicability of surgery or other local treatment techniques. B Management of metastases (perioperative treatment): avoid offering perioperative systemic treatment in patients with resectable metastases with favorable prognostic criteria and a good surgical approach. D Show 2 more Management of metastases, liver metastases: As per ASCO 2023 guidelines, consider offering stereotactic body radiotherapy following systemic therapy in patients with oligometastases of the liver ineligible for resection. C Show 2 more https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 10/17 6/24/23, 2:57 PM Rectal cancer Pathway As per ESMO 2023 guidelines, consider performing thermal ablation of small metastases in patients with unresectable colorectal liver metastases or oligometastatic disease in the liver. C Show 4 more Management of metastases, peritoneal metastases: As per ASCO 2023 guidelines: Consider performing cytoreductive surgery combined with systemic chemotherapy in selected patients with colorectal peritoneal metastases. C Do not offer oxaliplatin-based hyperthermic intraperitoneal chemotherapy as an addition to cytoreductive surgery in patients with colorectal peritoneal metastases. D As per ESMO 2023 guidelines, perform complete cytoreductive surgery in patients with peritoneal metastasis only. B Consider adding hyperthermic intraperitoneal chemotherapy only within clinical trials. B As per ASCRS 2022 guidelines, consider performing cytoreductive surgery, with or without intraperitoneal chemotherapy, in patients with coloRC and resectable peritoneal metastasis. B Management of metastases (lung metastases): consider performing thermal ablation along with resection in patients with lung-only metastases or oligometastatic disease including lung lesions, according to tumor size, number, location, the extent of lung parenchyma loss, comorbidity, or other factors. C Management of acute complications (general principles): follow the principles of optimal oncologic therapy when possible in patients with RC presenting with tumor-related emergencies, depending on the specific clinical circumstances. B Management of acute complications (obstruction): consider performing decompression with a proximal diverting stoma in patients with obstruction due to extraperitoneal RC. B Management of acute complications (perforation): Control the source of sepsis when diffuse peritonitis occurs in cancer-related colon perforation. Initiate prompt combined medical treatment. B Perform simultaneous tumor resection and management of proximal perforation in patients with perforation proximal to the tumor site (diastasic). Consider performing subtotal colectomy depending on the colonic wall conditions. B Management of acute complications (unstable patients): Initiate damage control treatment in unstable patients with perforation/obstruction having any of the following: pH < 7.2 core temperature < 35 C base excess < - 8 laboratory/clinical evidence of coagulopathy any signs of sepsis/septic shock, including the necessity of inotropic support. B Show 6 more Management of acute complications (antibiotic therapy): https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 11/17 6/24/23, 2:57 PM Rectal cancer Pathway Administer antibiotic prophylaxis mainly targeting Gram-negative bacilli and anaerobic bacteria in patients with coloRC obstruction and no systemic signs of infection because of the potential ongoing bacterial translocation. Discontinue prophylactic antibiotics after 24 hours (or 3 doses). A Take into consideration bacterial resistance for antibiotic therapy in patients with perforated coloRC and refine therapy according to the microbiological findings once available. B 6. Surgical interventions Technical considerations for ostomy surgery, preoperative care: As per SAGES/ASCRS 2023 guidelines, conduct a preoperative discussion regarding clinical milestones and discharge criteria. B Show 6 more As per ASCRS 2020 guidelines, mark the stoma site and provide preoperative education in patients planned for temporary or permanent ostomy. B Technical considerations for ostomy surgery (perioperative care): implement a multimodal, opioid-sparing pain management plan before the induction of anesthesia. B Show 7 more Technical considerations for ostomy surgery (choice of surgical approach): Use a minimally invasive surgical approach for colorectal resection when appropriate and provided expertise is available. A Avoid using nasogastric tubes and intra-abdominal drains for colorectal surgery. D Landmark trials: COLOR II In adult patients with rectal cancer within 15 cm from the anal verge without evidence of distant metastases, laparoscopic surgery was noninferior to open surgery with respect to a disease- free survival at 3 years. H Jaap Bonjer et al. N Engl J Med. 2015 Apr 2. Technical considerations for ostomy surgery (postoperative care): offer early and progressive patient mobilization for a shorter length of stay. B Show 6 more 7. Preventative measures Aspirin for primary prevention: As per ACG 2021 guidelines: https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 12/17 6/24/23, 2:57 PM Rectal cancer Pathway Consider initiating low-dose aspirin to reduce the risk of coloRC in 50-69 years old patients with 10% CVD risk over the next 10 years, no increased risk for bleeding, and willing to take aspirin for at least 10 years. C Do not use aspirin as a substitute for coloRC screening. D As per AGA 2021 guidelines, initiate low-dose aspirin to reduce coloRC incidence and mortality in < 70 years old individuals at average risk for coloRC meeting all the following criteria: 10% 10-year CVD risk life expectancy of 10 years not deemed at high risk for bleeding. E As per USPSTF 2016 guidelines, initiate low-dose aspirin for the primary prevention of CVD and coloRC in 50-59 years old individuals with all of the following: 10% 10-year CVD risk life expectancy of 10 years no increased risk of bleeding willing to take low-dose aspirin daily for at least 10 years. B Show 2 more Aspirin for secondary prevention: consider initiating aspirin to prevent recurrent colorectal neoplasia in patients with a history of coloRC. E Primary prevention in IBD: Initiate mesalazine at least 2 g/day to reduce the risk of coloRC in patients with ulcerative colitis or unclassified IBD with left-sided or more extensive disease. B Consider initiating thiopurines to reduce the risk of coloRC in patients with ulcerative colitis or unclassified IBD. C Primary prevention in PSC: do not use UDCA for the prevention of coloRC in patients with PSC. D Primary prevention in T2DM: Consider initiating metformin to prevent colorectal neoplasia in patients with T2DM. E Consider initiating metformin to reduce mortality in patients with coloRC and T2DM. E Agents with no evidence for benefit: do not use non-aspirin NSAIDs for the prevention of colorectal neoplasia in individuals at average risk for coloRC. D Show 3 more 8. Follow-up and surveillance Surveillance after curative-intent therapy: As per ESMO 2023 guidelines: Obtain radiological evaluation every 8-12 weeks, including (in most cases) CT or MRI, as well as serum CEA level measurements in patients with metastatic disease receiving active https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 13/17 6/24/23, 2:57 PM Rectal cancer Pathway treatment. B Obtain more intense monitoring initially with a radiological assessment with CT (or MRI) and measurements of CEA level every 3 months during the first 2 years and every 6 months thereafter in patients with a radically resected metastatic disease with potential for cure. A As per ASTRO 2021 guidelines: Obtain rectal protocol MRI and abdominopelvic CT and perform proctoscopy/sigmoidoscopy with DRE 2-3 months after completion of adjuvant chemoradiotherapy to assess treatment response in patients with RC planned for nonoperative management. B Obtain surveillance with the following tests in patients with RC undergoing nonoperative management or local excision: Situation Guidance Every 3 months for the first 2 years, then every 6-12 months thereafter Proctoscopy/sigmoidoscopy with DRE Every 3-6 months for the first 2 years, then every 6-12 months thereafter Rectal protocol MRI Every 6-12 months for the first 2 years, then every 12 months thereafter. B Cross-sectional imaging of the chest, abdomen, and pelvis As per ESMO 2017 guidelines, obtain clinical assessment, pelvic imaging with MRI and/or CT, thoraco-abdominopelvic CT for distant metastases, and perform completion colonoscopy during follow-up evaluation of patients with RC. B Show 2 more As per USMSTF 2016 guidelines, perform high-quality perioperative clearing with colonoscopy in patients with coloRC, in order to detect synchronous cancer and detect and completely resect precancerous polyps. Perform it preoperatively or within a 3-6-month interval after surgery in patients with obstructive coloRC. B Show 4 more As per ASCRS 2015 guidelines, consider obtaining surveillance after resection with curative intent in selected patients with stage I RC with increased risk factors. C Show 7 more References 1. R Glynne-Jones, L Wyrwicz, E Tiret et al. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2017 Jul 1;28(suppl_4):iv22-iv40. Open 2. US Preventive Services Task Force, Karina W Davidson, Michael J Barry et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021 May 18;325 19 1965 1977. Open https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 14/17 6/24/23, 2:57 PM Rectal cancer Pathway 3. Y Nancy You, Karin M Hardiman, Andrea Bafford et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer. Dis Colon Rectum. 2020 Sep;63 9 1191 1222. Open 4. Jennifer Y Wo, Christopher J Anker, Jonathan B Ashman et al. Radiation Therapy for Rectal Cancer: Executive Summary of an ASTRO Clinical Practice Guideline. Pract Radiat Oncol. 2021 Jan-Feb;11 1 13 25. Open 5. Jon D Vogel, Seth I Felder, Anuradha R Bhama et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colon Cancer. Dis Colon Rectum. 2022 Feb 1;65 2 148 177. Open 6. G Argil s, J Tabernero, R Labianca et al. Localised colon cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2020 Oct;31 10 1291 1305. Open 7. A Cervantes, R Adam, S Rosell et al. Metastatic colorectal cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol. 2023 Jan;34 1 10 32. Open 8. Lamb CA, Kennedy NA, Raine T et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019 Dec;68 Suppl 3):s1-s106. Open 9. Jennifer L Irani, Traci L Hedrick, Timothy E Miller et al. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum. 2023 Jan 1;66 1 15 40. Open 10. Aasma Shaukat, Charles J Kahi, Carol A Burke et al. ACG Clinical Guidelines: Colorectal Cancer Screening 2021. Am J Gastroenterol. 2021 Mar 1;116 3 458 479. Open 11. Wolf AMD, Fontham ETH, Church TR et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018 Jul;68 4 250 281. Open 12. Steele SR, Chang GJ, Hendren S et al. Practice Guideline for the Surveillance of Patients After Curative Treatment of Colon and Rectal Cancer. Dis Colon Rectum. 2015 Aug;58 8 713 25. Open 13. Pisano M, Zorcolo L, Merli C et al. 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg. 2018 Aug 13;13 36. Open 14. Peter S Liang, Aasma Shaukat, Seth D Crockett. AGA Clinical Practice Update on Chemoprevention for Colorectal Neoplasia: Expert Review. Clin Gastroenterol Hepatol. 2021 Jul;19 7 1327 1336. Open 15. Douglas K Rex, C Richard Boland, Jason A Dominitz et al. Colorectal Cancer Screening: Recommendations for Physicians and Patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2017 Jul;112 7 1016 1030. Open 16. Rubin DT, Ananthakrishnan AN, Siegel CA et al. ACG Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol. 2019 Mar;114 3 384 413. Open 17. Marie E Faughnan, Johannes J Mager, Steven W Hetts et al. Second International Guidelines for the Diagnosis and Management of Hereditary Hemorrhagic Telangiectasia. Ann Intern Med. 2020 Dec 15;173 12 989 1001. Open 18. Charles J Kahi, C Richard Boland, Jason A Dominitz et al. Colonoscopy Surveillance after Colorectal Cancer Resection: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2016 Mar;111 3 337 46; quiz 347. Open https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 15/17 6/24/23, 2:57 PM Rectal cancer Pathway 19. Samir Gupta, David Lieberman, Joseph C Anderson et al. Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc. 2020 Mar;91 3 463 485.e5. Open 20. Van K Morris, Erin B Kennedy, Nancy N Baxter et al. Treatment of Metastatic Colorectal Cancer: ASCO Guideline. J Clin Oncol. 2023 Jan 20;41 3 678 700. Open 21. Chapman MH, Thorburn D, Hirschfield GM et al. British Society of Gastroenterology and UK PSC guidelines for the diagnosis and management of primary sclerosing cholangitis. Gut. 2019 Aug;68 8 1356 1378. Open 22. Arasaradnam RP, Brown S, Forbes A et al. Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition. Gut. 2018 Aug;67 8 1380 1399. Open 23. ASGE Standards of Practice Committee, Brooks D Cash, Ruben D Acosta et al. The role of endoscopy in the management of constipation. Gastrointest Endosc. 2014 Oct;80 4 563 565. Open 24. Sapna Syngal, Randall E Brand, James M Church et al. ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes. Am J Gastroenterol. 2015 Feb;110 2 223 62; quiz 263. Open 25. Ross H, Steele SR, Varma M et al. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum. 2014 Jan;57 1 5 22. Open 26. Angela N Bartley, Anne M Mills, Eric Konnick et al. Mismatch Repair and Microsatellite Instability Testing for Immune Checkpoint Inhibitor Therapy: Guideline From the College of American Pathologists in Collaboration With the Association for Molecular Pathology and Fight Colorectal Cancer. Arch Pathol Lab Med. 2022 Oct 1;146 10 1194 1210. Open 27. Bibbins-Domingo K. Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: U.S. Preventive Services Task Force. Ann Intern Med. 2016 Jun 21;164 12 836 45. Open 28. Monson JR, Weiser MR, Buie WD et al. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum. 2013 May;56 5 535 50. Open 29. Qingyang Feng, Weitang Yuan, Taiyuan Li et al. Robotic versus laparoscopic surgery for middle and low rectal cancer REAL short-term outcomes of a multicentre randomised controlled trial. 2022 Sep 7;S2468 1253 22 00248 5. Open 30. James Fleshman, Megan Branda, Daniel J Sargent et al. Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes: The ACOSOG Z6051 Randomized Clinical Trial. JAMA. 2015 Oct 6;314 13 1346 55. Open 31. Andrew R L Stevenson, Michael J Solomon, John W Lumley et al. Effect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in Rectal Cancer: The ALaCaRT Randomized Clinical Trial. JAMA. 2015 Oct 6;314 13 1356 63. Open 32. H Jaap Bonjer, Charlotte L Deijen, Gabor A Abis et al. A Randomized Trial of Laparoscopic versus Open Surgery for Rectal Cancer. N Engl J Med. 2015 Apr 2;372 14 1324 32. Open 33. Deborah Schrag, Qian Shi, Martin R Weiser et al. Preoperative Treatment of Locally Advanced Rectal Cancer. N Engl J Med. 2023 Jun 4. Online ahead of print. Open 34. Ronan J Kelly, Katherine Bever, Joseph Chao et al. Society for Immunotherapy of Cancer SITC clinical practice guideline on immunotherapy for the treatment of gastrointestinal cancer. J Immunother Cancer. https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 16/17 6/24/23, 2:57 PM Rectal cancer Pathway 2023 Jun;11 6):e006658. Open https://web.pathway.md/diseases/rec6RFC6XhYL0O8gz 17/17