Surgery is recommended for many patients diagnosed with colorectal cancer.

Timeframe for starting treatment

• Colorectal cancer – surgery should be completed within five weeks of completing investigations and the MDM if no neoadjuvant therapy is required.
• Rectal cancer with neoadjuvant therapy – surgery should be completed in eight to 12 weeks after completing neoadjuvant therapy.

Training and experience required of the surgeon

• Surgeon (FRACS or equivalent) with adequate training and experience and institutional cross-credentialing and the agreed scope of practice within this area.
• Specifically, for rectal surgery, surgeons must be sub-specialists with an appropriate level of training and experience and treat an appropriate caseload annually.

Documented evidence of the surgeon’s training and experience, including their specific (sub-specialty) experience with colorectal cancer and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having surgery, health services should have these features:

• stomal therapy support
• critical care support
• 24-hour medical staff availability
• 24-hour operating room access and intensive care unit
• diagnostic imaging
• pathology
• nuclear medicine imaging.

Some patients may benefit from radiation therapy:

• patients with high-risk rectal cancer (neoadjuvant therapy)
• patients with symptomatic, non-resectable locally advanced rectal cancer who may benefit from radiation therapy with or without concurrent chemotherapy given with palliative intent
• patients with colon cancer where the tumour has penetrated a fixed structure.

Timeframe for starting treatment

Neoadjuvant radiation therapy should begin within three weeks of the MDM.

Training and experience required of the appropriate specialists

The appropriate specialist should be a radiation oncologist (FRANZCR) with adequate training and experience with the agreed scope of practice in colorectal cancer.

The training and experience of the radiation oncologist should be documented.

Health service unit characteristics

To provide safe and quality care for patients having radiation therapy, health services should have these features:

• linear accelerator (LINAC) capable of image-guided radiation therapy (IGRT)
• dedicated CT planning
• access to MRI and PET imaging
• automatic record-verify of all radiation treatments delivered
• a treatment planning system
• trained medical physicists, radiation therapists and nurses with radiation therapy experience
• coordination for combined therapy with systemic therapy, especially where facilities are not co-located
• participation in Australian Clinical Dosimetry Service audits
• an incident management system linked with a quality management system.

Some patients may benefit from systemic therapy:

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

Timeframes for starting treatment

• Neoadjuvant chemotherapy should begin within three weeks of the MDM.
• Adjuvant chemotherapy should begin within eight weeks of surgery.

Training and experience required of the appropriate specialists

Medical oncologists must have training and experience of this standard:

• Fellow of the Royal Australian College of Physicians (or equivalent)
• adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Cancer nurses should have accredited training in these areas:

• anti-cancer treatment administration
• specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
• the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

• adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In a setting where no medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having systemic therapy, health services should have these features:

• a clearly defined path to emergency care and advice after hours
• access to diagnostic pathology including basic haematology and biochemistry, and imaging
• cytotoxic drugs prepared in a pharmacy with appropriate facilities
• occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019)
• guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
• coordination for combined therapy with radiation therapy, especially where facilities are not co-located
• appropriate molecular pathology access.

4.2.4 Targeted therapies and immunotherapy

There are several targeted therapies that may be used as part of treatment for colorectal cancer. These include bevacizumab and cetuximab, among others. They are only used for metastatic disease in conjunction with chemotherapy.

There is a role for immunotherapy in selected metastatic cancer cases and currently only in microsatellite unstable tumours.

4.2.5 Emerging therapies

The key principle for precision medicine is prompt and clinically oriented communication and coordination with an accredited laboratory and pathologist. Tissue analysis is integral for access to emerging therapies and, as such, tissue specimens should be treated carefully to enable additional histopathological or molecular diagnostic tests in certain scenarios.

There is an increasing role for molecular pathology including RAS status, BRAF status and MSI status, which will influence treatment options.

MMR testing should be done routinely on all primary tumours. Methylation testing for tumours showing MLH1 loss should be undertaken if available. Methylation effectively excludes lynch syndrome.

For metastatic disease, molecular pathology is important including RAS status, BRAF status and MMR.

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 emotional and psychological issues, including body image concerns, fatigue, quitting smoking, traumatic experiences, existential anxiety, treatment phobias, anxiety/depression, interpersonal problems and sexuality concerns
• potential isolation from normal support networks, particularly for rural patients who are staying away from home for treatment
• managing physical symptoms such as pain, weight loss, fatigue, altered bowel function and/or diarrhoea (patients can talk about managing these symptoms with specialist nurses such as a stomal therapy nurse or continence nurse)
• gastrointestinal symptoms (e.g. nausea, vomiting, mucositis and loss of appetite) as a result of chemotherapy, requiring optimal symptom control with medication and referral to a dietitian if dietary intake is affected
• odours and flatus arising from stomas, faecal or urinary fistulae (referral to continence nurses or stomal therapy nurses may be useful)
• assistance with managing complex medication regimens, multiple medications, assessment of side effects and assistance with difficulties swallowing medications – referral to a pharmacist may be required
• decline in mobility or functional status as a result of treatment
• reduced sexual interest and sexual dysfunction – particularly in stoma patients compared with patients with intact sphincters (Reese et al. 2014) – may require referral to medical specialists. Sensitive discussion and referral to a clinician skilled in this area may be appropriate
• erectile dysfunction and ejaculation dysfunction, which require sensitive discussion; referral to a clinician skilled in this area may be appropriate (Averyt & Nishimoto 2014)
• fertility issues for patients of reproductive age; refer to a fertility specialist before starting treatment
• assistance with beginning or resuming regular exercise with referral to an exercise physiologist or physiotherapist (COSA 2018; Hayes et al. 2019).

Early involvement of general practitioners may lead to improved cancer survivorship care following acute treatment. General practitioners can address many supportive care needs through good communication and clear guidance from the specialist team (Emery 2014).

Patients, carers and families may have these additional issues and needs:

• financial issues related to loss of income (through reduced capacity to work or loss of work) and additional expenses as a result of illness or treatment
• advance care planning, which may involve appointing a substitute decision-maker and completing an advance care directive
• legal issues (completing a will, care of dependent children) or making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability.

Cancer Council’s 13 11 20 information and support line can assist with information and referral to local support services.

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

Rehabilitation may be required at any point of the care pathway. If it is required before treatment, it is referred to as prehabilitation (see section 3.6.1).

All members of the multidisciplinary team have an important role in promoting rehabilitation. Team members may include occupational therapists, speech pathologists, dietitians, social workers, psychologists, physiotherapists, exercise physiologists and rehabilitation specialists.

To maximise the safety and therapeutic effect of exercise for people with cancer, all team members should recommend that people with cancer work towards achieving, and then maintaining, recommended levels of exercise and physical activity as per relevant guidelines. Exercise should be prescribed and delivered under the direction of an accredited exercise physiologist or physiotherapist with experience in cancer care (Vardy et al. 2019). The focus of intervention from these health professionals is tailoring evidence-based exercise recommendations to the individual patient’s needs and abilities, with a focus on the patient transitioning to ongoing self-managed exercise.

Other issues that may need to be dealt with include managing cancer-related fatigue, improving physical endurance, achieving independence in daily tasks, optimising nutritional intake, returning to work and ongoing adjustment to cancer and its sequels. Referrals to dietitians, psychosocial support, return-to-work programs and community support organisations can help in managing these issues.

The lead or nominated clinician should take responsibility for these tasks:

• discussing treatment options with patients and carers, including the treatment intent and expected outcomes, and providing a written version of the plan and any referrals
• providing patient and carers with information about the possible side effects of treatment, managing symptoms between active treatments, how to access care, self-management strategies and emergency contacts
• encouraging patients to use question prompt lists and audio recordings, and to have a support person present to aid informed decision making
• initiating a discussion about advance care planning and involving carers or family if the patient wishes.

The general practitioner plays an important role in coordinating care for patients, including helping to manage side effects and other comorbidities, and offering support when patients have questions or worries. For most patients, simultaneous care provided by their general practitioner is very important.

The lead clinician, in discussion with the patient’s general practitioner, should consider these points:

• the general practitioner’s role in symptom management, supportive care and referral to local services
• the patient’s general practitioner may have expertise with many conditions that arise during treatment
• the patient’s general practitioner may have specific knowledge about the patient or access to local resources to help with prehabilitation, rehabilitation psychosocial needs and family issues
• using a chronic disease management plan and mental health care management plan
• how to ensure regular and timely two-way communication about:
  • the treatment plan, including intent and potential side effects
  • supportive and palliative care requirements
  • the patient’s prognosis and their understanding of this
  • enrolment in research or clinical trials
  • changes in treatment or medications
  • the presence of an advance care directive or appointment of a substitute decision-maker
  • recommendations from the multidisciplinary team.

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