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.