The NCCN Colon/Rectal/Anal Cancer Guidelines panel believes that a multidisciplinary approach is necessary for managing colorectal cancer. The panel endorses the concept that treating patients in a clinical trial has priority over standard or accepted therapy. The recommended surgical procedure for resectable colon cancer is an en bloc resection and adequate lymphadenectomy. Adequate pathologic assessment of the resected lymph nodes is important with a goal of evaluating at least 12 nodes. Adjuvant therapy with FOLFOX (category 1), 5-FU/LV (category 2A), or capecitabine (category 2A) is recommended by the panel for patients with stage III disease, and as an option for patients with high-risk stage II disease (category 2A for all 3 treatment options). Patients with metastatic disease in the liver or lung should be considered for surgical resection if they are candidates for surgery and if all original sites of disease are amenable to resection (R0) and/or ablation. Preoperative chemotherapy can be considered as initial therapy in patients with synchronous or metachronous resectable metastatic disease or when a response to chemotherapy may convert a patient from an unresectable to a resectable state (i.e., conversion therapy). Adjuvant chemotherapy should be considered following resection of liver or lung metastases. The recommended post-treatment surveillance program for colon cancer patients includes serial CEA determinations; periodic chest, abdominal, and pelvic CT scans; colonoscopic evaluations; and a survivorship plan to manage long-term side effects of treatment, facilitate disease prevention, and promote a healthy lifestyle. Recommendations for patients with previously untreated disseminated metastatic disease represent a continuum of care in which lines of treatment are blurred rather than discrete. Principles to consider at the start of therapy include pre-planned strategies for altering therapy for patients in both the presence and absence of disease progression, including plans for adjusting therapy for patients who experience certain toxicities. Recommended initial therapy options for advanced or metastatic disease depend on whether or not the patient is appropriate for intensive therapy. The more intensive initial therapy options include FOLFOX, FOLFIRI, CapeOX, and FOLFOXIRI (category 2B). Addition of a biologic agent (e.g., bevacizumab or cetuximab) is either recommended, or listed as an option, in combination with some of these regimens, depending on available data. Chemotherapy options for patients with progressive disease are dependent on the choice of initial therapy. © Journal of the National Comprehensive Cancer Network 2009.
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