What are the NCCN guidelines on chemotherapy for colorectal cancers?

Updated: Mar 18, 2021
  • Author: Elwyn C Cabebe, MD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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National Comprehensive Cancer Network (NCCN) guidelines recommend the use of as many chemotherapy drugs as possible to maximize the effect of adjuvant therapies for colon and rectal cancer. [11, 23]

The American Society of Clinical Oncology does not recommend the routine use of adjuvant chemotherapy for patients with stage II colon cancer, and instead recommends encouraging these patients to participate in clinical trials. [24]

According to the NCCN, stage I (T1-2, N0, M0) rectal cancer patients do not require adjuvant therapy due to their high cure rate with surgical resection. High-risk patients, including those with poorly differentiated tumor histology and those with lymphovascular invasion, should be considered for adjuvant chemotherapy and radiotherapy.

The NCCN guidelines recommend combination therapy with infusional fluorouracil, folinic acid, and oxaliplatin (FOLFOX) as reasonable for patients with high-risk or intermediate-risk stage II disease; however, FOLFOX is not indicated for good- or average-risk stage II rectal cancer.

Adjuvant chemotherapy is encouraged for eligible patients with stage III disease. NCCN recommendations for stage III treatment vary according to risk status. For low-risk stage III colon cancer (T1-3, N1), preferred treatments are as follows [11] :

  • Capecitabine plus oxaliplatin (CapeOx) for 3 months  or
  • FOLFOX for 3–6 months (category 1 for 6 months)

For high-risk stage III colon cancer (T4, N1-2; T any, N2), preferred treatment recommendations include the following:

  • CapeOx for 3–6 months (category 1 for 6 mo)  or
  • FOLFOX for 6 months (category 1) 

For both low-risk and high-risk colon cancer, other options include capecitabine or 5-fluorouracil (5-FU) for 6 months.

For more information on chemotherapy regimens, see Colon Cancer Treatment Protocols. For the majority of patients with stage II or stage III rectal cancer, the NCCN recommends the use of ionizing radiation to the pelvis along with adjuvant chemotherapy. Either of the two following sequences of therapy may be used [23] :

  • Chemoradiation therapy preoperatively and chemotherapy postoperatively
  • Chemotherapy followed by chemoradiation therapy, followed by resection

The NCCN advises that the total duration of perioperative therapy, including chemoradiation therapy and chemotherapy, should not exceed 6 months.

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