Colorectal cancer

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.

Prevention

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.

Checklist

Individual risk of developing cancer assessed

Education on screening recommendations appropriate to the patient’s risk

Encourage NBCSP iFOBT to eligible patients

Recent weight changes discussed and weight recorded

Alcohol intake discussed and recorded and support for reducing alcohol consumption offered if appropriate

Smoking status discussed and recorded and brief smoking cessation advice offered to smokers

Physical activity recorded

Referral to a dietitian, physiotherapist or exercise physiologist considered

Education on being sun smart considered

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.

Communication

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.

Checklist

Signs, symptoms and iFOBT recorded

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Patient notified of support services such as Cancer Council 13 11 20

Referral options discussed with the patient and/or carer including cost implications

Timeframe

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.

Communication

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.

Checklist

Diagnosis confirmed

Full histology obtained

Performance status and comorbidities measured and recorded

Patient discussed at an MDM and decisions provided to the patient and/or carer

Clinical trial enrolment considered

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Patient referred to support services (such as Cancer Council) as required

Treatment costs discussed with the patient and/or carer

Timeframe

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

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.

Communication

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.

Checklist

Intent of treatment established

Risks and benefits of treatments discussed with the patient and/or carer

Treatment plan discussed with the patient and/or carer

Treatment plan provided to the patient’s GP

Treating specialist has adequate qualifications, experience and expertise

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Early referral to palliative care considered

Advance care planning discussed with the patient and/or carer

Timeframe

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.

Communication

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.

Checklist

Treatment and follow-up summary provided to the patient and/or carer and the patient’s GP

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Patient-reported outcome measures recorded

Detection

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

Treatment

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.

Communication

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.

Checklist

Treatment intent, likely outcomes and side effects explained to the patient and/or carer and the patient’s GP

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Advance care planning discussed with the patient and/or carer

Patient referred to palliative care if appropriate

Routine follow-up visits scheduled

Palliative care

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

Communication

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.

Checklist

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Patient referred to palliative care

Advance care directive in place

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.

Colorectal cancer QRG

Colorectal cancer QRG

Colorectal cancer