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Colon cancer

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Updated 2023 AGA guidelines on screening for colorectal cancer.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of colon cancer are prepared by our editorial team based on guidelines from the European Society of Medical Oncology (ESMO 2024,2023,2020), the American College of Physicians (ACP 2023), the American Gastroenterological Association (AGA 2023,2021), the American Society of Clinical Oncology (ASCO 2023,2022,2019), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES/ASCRS ...
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Screening and diagnosis

Indications for screening, risk stratification: as per AGA 2023 guidelines, obtain risk stratification for initiation of CRC screening based on the patient's age, known or suspected predisposing hereditary colorectal syndromes, and/or a family history of CRC.
E
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  • Indications for screening (general population, aged 45-49 years)

  • Indications for screening (general population, aged 50-75 years)

  • Indications for screening (general population, aged 76-85 years)

  • Indications for screening (high-risk individuals, family history)

  • Indications for screening (high-risk individuals, hereditary cancer syndromes)

  • Indications for screening (high-risk individuals, IBD)

  • Indications for screening (high-risk individuals, PSC)

  • Indications for screening (high-risk individuals, HHT)

  • Choice of screening tests (primary choice)

  • Choice of screening tests (alternative choices)

  • Indications for testing (lower gastrointestinal bleeding)

  • Indications for testing (chronic diarrhea)

  • Indications for testing (chronic constipation)

Classification and risk stratification

Staging: as per ASCRS 2022 guidelines, use the AJCC TNM system for staging CC.
B
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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 CC.
B
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  • Laboratory tests

  • Imaging for staging (CT/MRI)

  • Imaging for staging (PET)

  • Evaluation in emergency settings

Diagnostic procedures

Diagnostic colonoscopy
As per ESMO 2020 guidelines:
Perform a total colonoscopy for diagnostic confirmation of CC 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
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  • Biopsy and histopathology (general principles)

  • Biopsy and histopathology (technical considerations)

  • Molecular testing (dMMR/MSI status)

  • Molecular testing (specific gene mutations)

  • Molecular testing (DPD deficiency)

  • Molecular testing (other tests)

Medical management

Management of nonmetastatic disease, neoadjuvant therapy: as per ASCRS 2022 guidelines, consider offering neoadjuvant chemotherapy or radiotherapy for tumor regression and facilitation of margin-negative excision in patients with locally advanced CC.
C
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  • Management of nonmetastatic disease (surgical resection)

  • Management of nonmetastatic disease (adjuvant chemoradiotherapy, timing)

  • Management of nonmetastatic disease (adjuvant chemoradiotherapy, stage II)

  • Management of nonmetastatic disease (adjuvant chemoradiotherapy, stage III)

  • Management of nonmetastatic disease (recurrence)

  • Management of metastatic disease (general principles)

  • Management of metastatic disease (surgical resection)

  • Management of metastatic disease (systemic therapy, first-line)

  • Management of metastatic disease (systemic therapy, maintenance)

  • Management of metastatic disease (systemic therapy, second-line)

  • Management of metastatic disease (systemic therapy, subsequent lines)

  • Management of metastatic disease (palliative interventions)

  • Management of metastases (general principles)

  • Management of metastases (perioperative treatment)

  • Management of metastases (liver metastases)

  • Management of metastases (peritoneal metastases)

  • Management of metastases (lung metastases)

  • Management of acute complications (left-sided colon obstruction)

  • Management of acute complications (right-sided colon obstruction)

  • Management of acute complications (perforation)

  • Management of acute complications (lower gastrointestinal bleeding)

  • Management of acute complications (unstable patients)

  • Management of acute complications (antibiotic therapy)

Surgical interventions

Technical considerations for surgery, preoperative care: as per ASCRS/SAGES 2023 guidelines, conduct a preoperative discussion regarding clinical milestones and discharge criteria.
B
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  • Technical considerations for surgery (perioperative care)

  • Technical considerations for surgery (choice of surgical approach)

  • Technical considerations for surgery (postoperative care)

Specific circumstances

Elderly patients: as per ASCRS 2022 guidelines, take into account the degree of frailty (physiological age) rather than chronological age of patients when making treatment decisions about colorectal surgery.
A
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Preventative measures

Aspirin for primary prevention
As per ACG 2021 guidelines:
Consider initiating low-dose aspirin to reduce the risk of CRC 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 CRC screening.
D
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  • Aspirin for secondary prevention

  • Primary prevention in IBD

  • Primary prevention in PSC

  • Primary prevention in T2DM

  • Agents with no evidence for benefit

Follow-up and surveillance

Surveillance after curative-intent therapy, general principles
As per ESMO 2020 guidelines:
Obtain intensive follow-up for earlier detection of relapses in at-risk patients with CC.
B
Implement long-term follow-up, rehabilitation, and survivorship care programs aiming at the detection of recurrent or new cancers, assessment and management of late and psychosocial effects, and implementation of health promotion measures.
B
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  • Surveillance after curative-intent therapy (clinical assessment and laboratory tests)

  • Surveillance after curative-intent therapy (surveillance imaging)

  • Surveillance after curative-intent therapy (surveillance colonoscopy)