STEP 3: Diagnosis, staging and treatment planning

Step 3 outlines the process for confirming the diagnosis and stage of cancer and for planning subsequent treatment. The guiding principle is that interaction between appropriate multidisciplinary team members should determine the treatment plan.

The treatment team, after taking a thorough medical history and making a thorough medical examination of the patient, should undertake the following investigations under the guidance of a specialist.

Patients thought to have resectable or potentially curable disease should have routine blood tests (full blood count [FBC], urea and electrolytes [U&E], liver function tests [LFT], carcinoembryonic antigen [CEA]), a complete colonic assessment by colonoscopy, or virtual colonoscopy in the case of an impassable tumour plus the following, as clinically indicated:

For colon and rectal cancer:

  • computed tomography (CT) scan of the chest, abdomen and pelvis
  • if CT shows metastatic disease confined to the liver, MRI of the liver to assess for resectability
  • PET-CT – this is recommended for patients who have suspicious metastatic disease at initial staging. It also recommended for restaging for those who have potentially resectable/treatable metastatic disease.

For rectal cancer:

  • endorectal ultrasound to assess T1 and early T2 tumours in patients who may be appropriate for local resection techniques.

It is essential that the treating surgeon accurately assesses the tumour location.

Investigations should be completed within two weeks.

Between 10 and 15 per cent of colorectal cancers will present as an emergency. This necessitates appropriate acute care followed by management from a multidisciplinary team.

Between 1 and 5 per cent of colorectal cancers are specifically inherited (familial adenomatous polyposis and lynch syndrome) and up to 25 per cent may have some inherited component. The features that suggest a genetic predisposition may include:

  • early age at onset
  • multiple primary cancers
  • multiple polyps
  • the histological type of polyp(s)
  • family history of similar or related cancers.

Universal testing for mismatch repair deficiency by IHC or MSI testing is now recommended as standard practice for treatment-related and familial risk assessments.

Anyone diagnosed with cancer should have a detailed personal and family cancer history taken. People with a strong family history of colorectal cancer or high-risk familial syndromes should be referred to a familial cancer service for genetic risk assessment and possible genetic screening of affected relatives. Younger patients under 50 years should be referred to a familial cancer service. Consult relevant guidelines to determine if referral to a familial cancer service is appropriate.

Mainstream genetic testing is now available and funded through Medicare for the mismatch repair genes, APC, MUTYH and the hamartomatous polyposis genes. However, a familial cancer service assessment can assist and determine if genetic testing is appropriate. Genetic testing should be offered when there is at least a 10 per cent chance of finding a causative ‘gene error’ (pathogenic gene variant; previously called a mutation). Tumour testing for mismatch repair (MMR) protein expression or microsatellite testing is the main avenue to determining this risk for lynch syndrome. Usually testing begins with a variant search in a person who has had cancer (a diagnostic genetic test). If a pathogenic gene variant is identified, variant-specific testing is available to relatives to see if they have inherited the familial gene variant (predictive genetic testing). Depending on the personal and family history, the relevant state health system may support funding in the public sector for additional germline testing.

Pre-test counselling and informed consent is required before any genetic testing in any setting. A familial cancer service can organise this, as well as provide risk management advice, facilitate family risk notification and arrange predictive cascade genetic testing for the family.

Visit the Centre for Genetics Education website for basic information about cancer in a family.

For detailed information and referral guidelines for colorectal cancer risk assessment and consideration of genetic testing, see these resources:

Pharmacogenetics describes how individual genetic differences can lead to differences in the way certain medicines interact with the body. These interactions can affect the effectiveness of medications and any side effects. Applying pharmacogenetics to treatment planning may help patients to be prescribed the most appropriate treatment at the optimal dose from the beginning of treatment (NHMRC 2013).

Staging is a critical element in treatment planning and should be clearly documented in the patient’s medical record.

Preoperative staging, including the investigations listed in section 3.1, is used to define the extent of tumour spread and to determine neoadjuvant therapy use.

  • Clinical pathological staging will occur after surgery and is needed to inform post-treatment care.
  • Synoptic reporting is recommended.
  • Screen for loss of expression of MMR protein in all patients at the time of biopsy and after tumour resection.
More information

Visit the Cancer Institute New South Wales website for information about understanding the stages of cancer.

Patient performance status is a central factor in cancer care and should be clearly documented in the patient’s medical record.

Performance status should be measured and recorded using an established scale such as the Karnofsky scale or the Eastern Cooperative Oncology Group (ECOG) scale.

A number of factors should be considered at this stage:

  • the patient’s overall condition, life expectancy, personal preferences and decision- making capacity
  • discussing the multidisciplinary team approach to care with the patient
  • appropriate and timely referral to an MDM
  • pregnancy and fertility
  • support with travel and accommodation
  • teleconferencing or videoconferencing as required.

The multidisciplinary team should meet to discuss newly diagnosed patients within two weeks of diagnosis and staging so that a treatment plan can be recommended and there can be early preparation for the post-treatment phase. The level of discussion may vary, depending on the patient’s clinical and supportive care factors. Some patients with non-complex cancers may not be discussed by a multidisciplinary team; instead the team may have treatment plan protocols that will be applied if the patient’s case (cancer) meets the criteria. If patients are not discussed at an MDM, they should at least be named on the agenda for noting. The proposed treatment must be recorded in the patient’s medical record and should be recorded in an MDM database where one exists.

Teams may agree on standard treatment protocols for non-complex care, facilitating patient review (by exception) and associated data capture.

Results of all relevant tests and access to images should be available for the MDM. Information about the patient’s concerns, preferences and social and cultural circumstances should also be available.

The multidisciplinary team requires administrative support in developing the agenda for the meeting, for collating patient information and to ensure appropriate expertise around the table to create an effective treatment plan for the patient. The MDM has a chair and multiple lead clinicians. Each patient case will be presented by a lead clinician (usually someone who has seen the patient before the MDM). In public hospital settings, the registrar or clinical fellow may take this role. A member of the team records the outcomes of the discussion and treatment plan in the patient history and ensures these details are communicated to the patient’s general practitioner. The team should consider the patient’s values, beliefs and cultural needs as appropriate to ensure the treatment plan is in line with these.

The multidisciplinary team should be composed of the core disciplines that are integral to providing good care. Team membership should reflect both clinical and supportive care aspects of care. Pathology and radiology expertise are essential.

See ‘About this OCP’ for a list of team members who may be included in the multidisciplinary team for colorectal cancer.

Core members of the multidisciplinary team are expected to attend most MDMs either in person or remotely via virtual mechanisms. Additional expertise or specialist services may be required for some patients. An Aboriginal and Torres Strait Islander cultural expert should be considered for all patients who identify as Aboriginal or Torres Strait Islander.

The general practitioner who made the referral is responsible for the patient until care is passed to another practitioner who is directly involved in planning the patient’s care.

The general practitioner may play a number of roles in all stages of the cancer pathway including diagnosis, referral, treatment, shared follow-up care, post-treatment surveillance, coordination and continuity of care, as well as managing existing health issues and providing information and support to the patient, their family and carer.

A nominated contact person from the multidisciplinary team may be assigned responsibility for coordinating care in this phase. Care coordinators are responsible for ensuring there is continuity throughout the care process and coordination of all necessary care for a particular phase (COSA 2015). The care coordinator may change over the course of the pathway.

The lead clinician is responsible for overseeing the activity of the team and for implementing treatment within the multidisciplinary setting.

Patients should be encouraged to participate in research or clinical trials where available and appropriate.

For more information visit the Cancer Australia website.

Cancer prehabilitation uses a multidisciplinary approach combining exercise, nutrition and psychological strategies to prepare patients for the challenges of cancer treatment such as surgery, systemic therapy and radiation therapy. Team members may include anaesthetists, oncologists, surgeons, haematologists, clinical psychologists, exercise physiologists, physiotherapists and dietitians, among others.

Patient performance status is a central factor in cancer care and should be frequently assessed. All patients should be screened for malnutrition using a validated tool, such as the Malnutrition Screening Tool (MST). The lead clinician may refer obese or malnourished patients to a dietitian preoperatively or before other treatments begin.

Patients who currently smoke should be encouraged to stop smoking before receiving treatment. This should include an offer of referral to Quitline in addition to smoking cessation pharmacotherapy if clinically appropriate.

Evidence indicates that patients who respond well to prehabilitation may have fewer complications after treatment. For example, those who were exercising before diagnosis and patients who use prehabilitation before starting treatment may improve their physical or psychological outcomes, or both, and this helps patients to function at a higher level throughout their cancer treatment (Cormie et al. 2017; Silver 2015).

For patients with colorectal cancer, the multidisciplinary team should consider these specific prehabilitation assessments and interventions for treatment-related complications or major side effects:

  • conducting a physical and psychological assessment to establish a baseline function level
  • identifying impairments and providing targeted interventions to improve the patient’s function level (Silver & Baima 2013)
  • referral to a stoma nurse
  • reviewing the patient’s medication to ensure optimisation and to improve adherence to medicine used for comorbid conditions.

Following completion of primary cancer treatment, rehabilitation programs have considerable potential to enhance physical function.

Cancer and cancer treatment may cause fertility problems. This will depend on the age of the patient, the type of cancer and the treatment received. Infertility can range from difficulty having a child to the inability to have a child. Infertility after treatment may be temporary, lasting months to years, or permanent (AYA Cancer Fertility Preservation Guidance Working Group 2014).

Patients need to be advised about and potentially referred for discussion about fertility preservation before starting treatment and need advice about contraception before, during and after treatment. Patients and their family should be aware of the ongoing costs involved in optimising fertility. Fertility management may apply in both men and women. Fertility preservation options are different for men and women and the need for ongoing contraception applies to both men and women.

A diagnosis of colorectal cancer in reproductive-age women may carry a risk of future infertility. Therefore, the risk of infertility, and fertility preservation options, both before and after cancer therapy, should be discussed with patients and their families as part of the initial cancer management planning. This discussion should be ongoing, with firm follow-up arrangements put into place. All discussions should be documented in the patient’s medical record.

Treatment for colorectal cancer may reduce female fertility through damage to the ovaries (from chemotherapy or radiation), damage to the uterus (from radiation) and potentially through damage to the fallopian tubes from abdominal surgery. Chemotherapy, especially with alkylating agents, is likely to reduce ovarian reserve, leading to a reduced fertility window or premature menopause. The type of chemotherapy will determine the extent of infertility associated with follicle loss. Radiation of the pelvis commonly induces permanent ovarian failure and may damage the uterus such that future pregnancy confers risk to the mother and fetus.

Pelvic radiation may also induce vaginal adhesions or stenosis, limiting future sexual activity. This risk can be reduced by using vaginal cylinders and topical oestrogen treatment.

Fertility preservation interventions including egg or embryo freezing and ovarian tissue cryopreservation offer realistic options for having a family, although sometimes egg donation and surrogacy may ultimately be required. Women of reproductive age who are concerned about future fertility should be referred to a fertility specialist to discuss potential fertility preservation interventions. Women with early menopause due to colorectal cancer treatment should be offered hormone replacement therapy and (if possible) managed by a menopause specialist.

Some colorectal cancers may be associated with a genetic risk, and specific gene testing in IVF embryos may reduce transmission risk. Some gastrointestinal cancers may be associated with a high risk of other cancers including uterine cancers. Careful counselling and surveillance are required, especially if future pregnancy is a consideration.

An early, collaborative and multidisciplinary approach with the Medical Services Advisory Committee and the surgical, oncology and fertility preservation teams will maximise the opportunity for best practice care and consideration for future fertility for young women diagnosed with colorectal cancer.

More information

See the Cancer Council website for more information.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

  • assistance for dealing with psychological and emotional distress while adjusting to the diagnosis; treatment phobias; existential concerns; stress; difficulties making treatment decisions; anxiety or depression or both; psychosexual issues such as potential loss of fertility and premature menopause; history of sexual abuse; and interpersonal problems
  • management of physical symptoms such as pain, fatigue (Australian Adult Cancer Pain Management Guideline Working Party 2019), weight loss and altered bowel function
  • malnutrition or undernutrition, identified using a validated nutrition screening tool such as the MST (note that many patients with a high BMI [obese patients] may also be malnourished [WHO 2018])
  • pre-surgical education with a stomal therapy nurse wherever a temporary or permanent stoma is a possibility
  • guidance for financial and employment issues (e.g. loss of income, travel and accommodation)
  • requirements for rural patients and caring arrangements for other family members
  • support for families or carers who are distressed with the patient’s cancer diagnosis
  • support for families/relatives who may be distressed after learning of a genetically linked cancer diagnosis
  • specific spiritual needs that may benefit from the involvement of pastoral/spiritual care
  • low self-esteem and disturbed body image, which are more prevalent in stoma patients than in non-stoma patients.

Between 32 and 44 per cent of patients report psychological distress following a diagnosis of colorectal cancer, and patients with stomas are at higher risk (El-Shami et al. 2015; Cancer Council Australia Colorectal Cancer Guidelines Working Party 2019). This large number indicates a need for screening patients to identify those at high risk of anxiety or depression at each visit. Provide patients with tailored and accurate information before treatment, and facilitate patient decision making about appearance-altering treatment and meeting others with a similar personal experience (Hong et al. 2014). Consider pre-surgical referral to a psycho-oncologist for support over body image expectations associated with surgical treatment.

Additionally, palliative care may be required at this stage.

For more information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.

In discussion with the patient, the lead clinician should undertake the following:

  • establish if the patient has a regular or preferred general practitioner and, if the patient does not have one, then encourage them to find one
  • provide written information appropriate to the health literacy of the patient about the diagnosis and treatment to the patient and carer and refer the patient to the Guide to best cancer care (consumer optimal care pathway) for bowel cancer, as well as to relevant websites and support groups as appropriate
  • provide a treatment care plan including contact details for the treating team and information on when to call the hospital
  • discuss a timeframe for diagnosis and treatment with the patient and carer
  • discuss the benefits of multidisciplinary care and gain the patient’s consent before presenting their case at an MDM
  • provide brief advice and refer to Quitline (13 7848) for behavioural intervention if the patient currently smokes (or has recently quit), and prescribe smoking cessation pharmacotherapy, if clinically appropriate
  • recommend an ‘integrated approach’ throughout treatment regarding nutrition, exercise and minimal or no alcohol consumption among other considerations
  • communicate the benefits of continued engagement with primary care during treatment for managing comorbid disease, health promotion, care coordination and holistic care
  • where appropriate, review fertility needs with the patient and refer for specialist fertility management (including fertility preservation, contraception, management during pregnancy and of future pregnancies)
  • be open to and encourage discussion about the diagnosis, prognosis (if the patient wishes to know) and survivorship and palliative care while clarifying the patient’s preferences and needs, personal and cultural beliefs and expectations, and their ability to comprehend the communication
  • encourage the patient to participate in advance care planning including considering appointing one or more substitute decision-makers and completing an advance care directive to clearly document their treatment preferences. Each state and territory has different terminology and legislation surrounding advance care directives and substitute decision-makers.

The lead clinician has these communication responsibilities:

  • involving the general practitioner from the point of diagnosis
  • ensuring regular and timely communication with the general practitioner about the diagnosis, treatment plan and recommendations from MDMs and inviting them to participate in MDMs (consider using virtual mechanisms)
  • supporting the role of general practice both during and after treatment
  • discussing shared or team care arrangements with general practitioners or regional cancer specialists, or both, together with the patient.
More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.