New consensus guidelines on the management of metastatic colorectal cancer

"Management of metastatic colorectal cancer is becoming more complex, requiring a strategic approach and evidence-based patient selection for the best treatment options," said chair of the ESMO Consensus Conference Professor Eric Van Cutsem, from the University Hospitals Gasthuisberg/Leuven and KU Leuven, Belgium.

In December 2014, ESMO convened an international consensus panel of experts with subgroups focusing on molecular pathology and biomarkers, local and ablative treatment and treatment of metastatic disease. The subsequent recommendations are based on a significant new body of clinical trial evidence and an advanced understanding of the role and impact of molecular selection.

One of the major innovations in the guidelines is the development of a detailed therapeutic algorithm that takes into account the patient's condition and fitness; therapeutic goals such as tumour shrinkage or slowing disease progression; and molecular markers. The guidelines also address questions such as the use of chemoembolization and radioembolisation, imaging, and surgical resection.

Recommendations made by the consensus panel include RAS and BRAF mutation testing at diagnosis for all patients with metastatic colorectal cancer. The guidelines also note that there is now growing evidence for more frequent testing for MSI. Testing emerging biomarkers such as EGFR or HER2 is not recommended as routine for patient management.

"Colon cancer management is making progress, leading patients who can be cured though multidisciplinary management of metastases, and to prolonged survival -- up from 6 months to 30 months -- in many patients," said Professor Van Cutsem .

This progress is also attributed to the use of combination chemotherapy and the development of novel second line agents including angiogenesis inhibitors, EGFR antibodies and new agents for chemorefractory disease such as regorafenib and trifluridine/tipiracil.

This second set of ESMO consensus guidelines for metastatic colorectal guidelines -- the first were published in 2012 -- integrates with the 2014 ESMO Clinical Practice Guidelines on metastatic colorectal cancer, which will be updated for publication in 2017.

Commenting on the guidelines, Dr Fotios Loupakis from the Ospedale Civile -- Istituto Toscano Tumori and member of the ESMO Faculty for Gastro-Intestinal Tumors, said, "With these long awaited guidelines, the management of metastatic colorectal cancer officially enters the personalized era, addressing the role of existing and emerging biomarkers and their role in the clinic."

"The new guidelines move from the clinically-defined historical categories --which were focused on the resectability of metastases, to a less sharp but more realistic assessment that gives more importance to additional elements, such as patient, tumour and treatment characteristics."