Colorectal cancer

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The optimal care pathways describe the standard of care that should be available to all cancer patients treated in Australia. The pathways support patients and carers, health systems, health professionals and services, and encourage consistent optimal treatment and supportive care at each stage of a patient’s journey. Seven key principles underpin the guidance provided in the pathways: patient-centred care; safe and quality care; multidisciplinary care; supportive care; care coordination; communication; and research and clinical trials.

This quick reference guide provides a summary of the Optimal care pathway for people with colorectal cancer.

Please note that not all patients will follow every step of the pathway.

Support: Assess supportive care needs at every step of the pathway and refer to appropriate health professionals or organisations.


Recommendations for reducing the risk of colorectal cancer:

  • completing the National Bowel Cancer Screening Program (NBCSP) at-home bowel cancer test, every 2 years if aged 50–74 years
  • eating a healthy diet, including plenty of vegetables, fruit and whole grains while minimising intake of red meat, barbequed/grilled meat and processed meat
  • maintaining a healthy body weight
  • undertaking regular physical activity
  • avoiding or limiting alcohol intake
  • not smoking.

Consider aspirin (100–300 mg per day) as a prevention measure for people who are 50–70 years old including those at an average risk of colorectal cancer, in conjunction with other comorbidities.

Early detection

The NBCSP invites people starting at age 50 and continuing to age 74 (at average risk and asymptomatic) to screen for bowel cancer using a free, simple test at home.

Screening recommendations

For category 1 (near average risk) patients, an immunochemical faecal occult blood test (iFOBT) is recommended every 2 years between 50 and 74 years of age.

For category 2 (moderately increased risk) patients, offer iFOBT every 2 years starting at age 40, then colonoscopy every 5 years starting at age 50.

For category 3 (high risk) patients, offer iFOBT every two years starting at age 35, then colonoscopy every 5 years from age 45 to age 74.

Refer to the colorectal cancer optimal care pathway for more about the risk categories.


The following signs, symptoms and results should be investigated:

  • positive iFOBT
  • passage of blood with or without mucus in faeces
  • unexplained iron deficiency anaemia
  • change in bowel habit (loose stools or constipation), especially a recent one
  • undiagnosed abdominal pain or tenderness
  • unexplained rectal or abdominal mass
  • unexplained weight loss
  • lethargy

Initial investigations include:

  • detailed family history for patients presenting with possible symptoms of colorectal cancer
  • physical examination
  • digital rectal examination
  • full blood examination and iron studies

Referral options

At the referral stage, the patient’s GP or other referring doctor should advise the patient about their options for referral, waiting periods, expertise, if there are likely to be out-of-pocket costs and the range of services available. This will enable patients to make an informed choice of specialist and health service.


The GP’s responsibilities include:

  • explaining to the patient and/or carer who they are being referred to and why
  • supporting the patient and/or carer while waiting for specialist appointments informing the patient and/ or carer that they can contact Cancer Council on 13 11 20.



Test results should be provided to the patient within 1 week of testing.

If symptoms suggest colorectal cancer, patients should be referred and colonoscopy completed within 4 weeks.

Patients should see a surgeon within 2 weeks of GP referral following a positive diagnosis of colorectal cancer via colonoscopy.

Diagnosis and staging

For colon and rectal cancer:

  • CT scan of the chest, abdomen and pelvis
  • MRI liver
  • PET-CT

For rectal cancer:

  • endorectal ultrasound

Genetic testing

Up to 5% of colorectal cancers are specifically inherited (familial adenomatous polyposis and lynch syndrome) and up to 25% may have some form of inherited component.

Find out more about colorectal cancer genetic testing.

Treatment planning

The multidisciplinary team should discuss all newly diagnosed patients within 2 weeks of diagnosis and staging.

Some cases of colorectal cancer present as emergencies and require appropriate acute care followed by management from a multidisciplinary team.

Research and clinical trials

Consider enrolment where available and appropriate. Search for a trial.


The lead clinician’s (1) responsibilities include:

  • discussing a timeframe for diagnosis and treatment options with the patient and/or carer
  • explaining the role of the multidisciplinary team in treatment planning and ongoing care
  • encouraging discussion about the diagnosis, prognosis, advance care planning and palliative care while clarifying the patient’s wishes, needs, beliefs and expectations, and their ability to comprehend the communication
  • providing appropriate information and referral to support services as required
  • communicating with the patient’s GP about the diagnosis, treatment plan and recommendations from multidisciplinary meetings (MDMs).

1: Lead clinician – the clinician who is responsible for managing patient care.

The lead clinician may change over time depending on the stage of the care pathway and where care is being provided.



Investigations should be completed within 2 weeks.

Establish intent of treatment

  • Curative
  • Anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
  • Symptom palliation


  • Surgery is recommended for many patients with colorectal cancer.
  • Surgeons should have adequate qualifications and expertise, especially those undertaking rectal surgery.

Radiation therapy

  • Neoadjuvant radiation therapy is recommended for those with high-risk rectal cancer.
  • Radiation therapy may be given with palliative intent in symptomatic, non-resectable, locally advanced colorectal cancer.
  • Radiation therapy may be suitable for patients with colon cancer where the tumour has penetrated a fixed structure.

Systemic therapy

Systemic therapy may be beneficial for patients with:

  • a high risk of relapse and who may benefit from adjuvant therapy
  • locally advanced (high-risk) rectal cancer, treated with chemoradiation therapy
  • non-resectable, locally advanced or metastatic disease.

Palliative care

Early referral to palliative care can improve quality of life and in some cases survival. Referral should be based on need, not prognosis. For more, visit the Palliative Care Australia website.


The lead clinician and team’s responsibilities include:

  • discussing treatment options with the patient and/or carer including the intent of treatment as well as risks and benefits
  • discussing advance care planning with the patient and/or carer where appropriate
  • communicating the treatment plan to the patient’s GP
  • helping patients to find appropriate support for exercise programs where appropriate to improve treatment outcomes.



Surgery conducted within 5 weeks of investigations and MDM if no neoadjuvant therapy is required for patients with colorectal cancer.

Surgery conducted 8–12 weeks after neoadjuvant therapy for patients with rectal cancer.

Neoadjuvant radiation and neoadjuvant chemotherapy should begin within 3 weeks of the MDM.

Adjuvant chemotherapy should begin within 8 weeks of surgery.

Provide a treatment and follow-up summary to the patient, carer and GP outlining:

  • the diagnosis, including tests performed and results
  • tumour characteristics
  • treatment received (types and date)
  • current toxicities (severity, management and expected outcomes)
  • interventions and treatment plans from other health professionals
  • potential long-term and late effects of treatment and care of these
  • supportive care services provided
  • a follow-up schedule, including tests required and timing
  • contact information for key healthcare providers who can offer support for lifestyle modification
  • a process for rapid re-entry to medical services for suspected recurrence.


The lead clinician’s responsibilities include:

  • explaining the treatment summary and follow-up care plan to the patient and/or carer
  • informing the patient and/or carer about secondary prevention and healthy living
  • discussing the follow-up care plan with the patient’s GP.



Most recurrent disease will be detected via routine follow-up or by the patient presenting with symptoms.


Evaluate each patient for whether referral to the original multidisciplinary team is appropriate. Treatment will depend on the location and extent of disease, previous management and the patient’s preferences.

Advance care planning

Advance care planning is important for all patients but especially those with advanced disease. It allows them to plan for their future health and personal care by thinking about their values and preferences. This can guide future treatment if the patient is unable to speak for themselves.

Survivorship and palliative care

Survivorship and palliative care should be addressed and offered early. Early referral to palliative care can improve quality of life and in some cases survival. Referral should be based on need, not prognosis.


The lead clinician and team’s responsibilities include:

  • explaining the treatment intent, likely outcomes and side effects to the patient and/or carer and the patient’s GP.


Palliative care

Consider a referral to palliative care. Ensure an advance care directive is in place.


The lead clinician’s responsibilities include:

  • being open about the prognosis and discussing palliative care options with the patient
  • establishing transition plans to ensure the patient’s needs and goals are considered in the appropriate environment.


Visit our guides to best cancer care webpage for consumer guides. Visit our OCP webpage for the optimal care pathway and instructions on how to import these guides into your GP software.