National Institute for Health and Clinical Excellence (NICE)
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New NICE guidance on the diagnosis and treatment of colorectal cancer

NICE, the healthcare guidance body, has yesterday published a new clinical guideline on best practice for the diagnosis and treatment of people with colorectal cancer.

The guideline will help health professionals to provide consistent care for patients with colorectal cancer, supporting patients with the disease and ensuring equal access to services across England and Wales.

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE, said: "Around 40,000 new cases of colorectal cancer are diagnosed in the UK each year. It is a treatable disease, but it needs to be identified early. Thisis the first NICE guideline to look at how best to diagnose and manage colorectal cancer and its aim is to help ensure patients are diagnosed quickly and accurately and receive the best possible care.

"Recommendations made in this new guideline emphasise the importance of ensuring patients have all the information they need, to enable them to make better informed decisions about their care, improving their quality of life during and after treatment."

Key recommendations include:

  • Diagnostic investigations: Patients who do not have any major comorbidities alongside suspected colorectal cancer should be offered a colonoscopy to confirm a diagnosis. If a lesion suspected of cancer is detected, a biopsy should be performed to obtain histological proof of diagnosis, unless it is contraindicated (for example, patients with a blood clotting disorder).
  • Staging of colorectal cancer Patients diagnosed with colorectal cancer should be offered contrast-enhanced computed tomography (CT) of the chest, abdomen and pelvis, to estimate the stage of disease, unless it is contraindicated.
  • Chemotherapy for advanced and metastatic colorectal cancer: When offering multiple chemotherapy drugs to patients with advanced and metastatic colorectal cancer, consider one of the following sequences of chemotherapy unless they are contraindicated:

    - FOLFOX (folinic acid plus fluorouracil plus oxaliplatin) as first-line treatment then single agent irinotecan as second-line treatment or

    - FOLFOX as first-line treatment then FOLFIRI (folinic acid plus fluorouracil plus irinotecan) as second-line treatment or
    - XELOX (capecitabine plus oxaliplatin) as first-line treatment then FOLFIRI (folinic acid plus fluorouracil plus irinotecan) as second-line treatment.

Decide which combination and sequence of chemotherapy to use after full discussion of the side effects and the patient's preferences.

  • Follow-up after surgery to remove cancer tumour Patients should be offered regular surveillance with: a minimum of two CT scans of the chest, abdomen, and pelvis in the first 3 years and regular serum carcinoembryonic antigen tests1 (at least every 6 months in the first 3 years).
  • Information about bowel function Before starting treatment, all patients should be offered information on all treatment options available to them (including no treatment it the patient chooses) and the potential benefits and risks of these treatments, including the effect on bowel function.

Mr Graeme Poston, Consultant Surgeon, Aintree University Hospital NHS Foundation Trust and Chair of the guideline development group said: "Wide variations in practice exist across the country in the diagnosis and management of colorectal cancer, and these variations are reflected in survival outcomes achieved. We believe that these guidelines will improve the diagnosis and treatment of colorectal cancer at every stage of the patient journey, and end any post code lottery of care to which patients have previously endured.

"The guideline will be followed next year by measurable Quality Standards for the management of colorectal cancer, with which health care commissioners will be able to directly measure the impact of these guidelines on individual hospital performance and the long-term outcomes for patients found to be suffering from colorectal cancer."

Dr Diana Tait, Consultant Clinical Oncologist/Associate Medical Director, Clinical Governance, The Royal Marsden NHS Foundation Trust and member of the guideline development group said: "There are numerous options available for the treatment of colorectal cancer and clinical teams often offer different options and patient experiences vary depending on location and individual clinician preferences.

"The new guideline offers a basis for decision-making in the areas of clinical management identified in the scoping process as the most challenging. Where there are gaps in the evidence, the guidelines also includes a number of recommendations for research to encourage clinicians and patients to take part in research studies. Through further research, lie the guidelines of the future."

Yvette Perston, Colorectal Clinical Nurse Specialist, Cardiff and Vale NHS Trust and member of the guideline development group said: "The publication of these guidelines provides nurses with clear direction on how to improve their care of these patients. It provides a diagnostic and treatment pathway for nurses to follow. Importantly it highlights the significance of the effect of treatment on bowel function and its subsequent effect on quality of life. This presents nurses with opportunities and clear indications of how they can positively change their practice to improve patient outcomes."

Christine Holman patient representative on the guideline development group said: "The new guideline emphasises the importance of providing the patient and their carers with comprehensive information, thereby enabling them to make informed decisions about their treatment choices, including the option of declining treatment. Our work in developing the guideline highlighted the dearth of information from patients about their experience of the very specific side effects relating to bowel function and daily living activities that can occur after treatment for colorectal cancer. We have made a strong recommendation for research in this important area."

Notes to Editors

About the guidance

1. The guidance will be available on the NICE website ( from 9 November 2011.

2. Colorectal cancer covers cancers in both the colon and the rectum. It is strongly related to age, with almost three-quarters of cases occurring in people aged 65 or over.

3. This new guideline does not cover the signs and symptoms and referral from primary care. The NICE clinical guideline on referral for suspected cancer aims to help general practitioners (GPs) make decisions about when to refer people to specialists when they present with symptoms that could be caused by cancer (

4. The Government's campaign to increase awareness of bowel cancer is to be rolled out nationally as part of a £8.5 million package following a successful trial. The ‘Be Clear on Cancer' bowel cancer awareness will launch nationally in January. The ads will feature real GPs encouraging patients to talk to them about changes in their poo. They aim to make people aware of the early signs of bowel cancer and make it easier for them to discuss this with their GP.

About NICE

1. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health

2. NICE produces guidance in three areas of health:

  • public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
  • health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
  • clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

3. NICE produces standards for patient care:

  • quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
  • Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients

4. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.

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