Guidelines doi:10.1111/codi.

13702

Association of Coloproctology of Great Britain & Ireland

(ACPGBI): Guidelines for the Management of Cancer of the
Colon, Rectum and Anus (2017) - Introduction
Brendan Moran*, Sharad Karandikar† and Ian Geh‡
*Basingstoke & North Hampshire Hospital, Basingstoke, UK, †Birmingham Heartlands Hospital, Birmingham, UK, and ‡Queen Elizabeth Hospital,
Birmingham, UK

1 Introduction 1.5 Radiology and Histopathology

1.1 Multidisciplinary teams 1.6 Chemotherapy and Radiotherapy
1.2 Prevention and earlier diagnosis 1.7 Outcomes and Survivorship
1.3 Laparoscopic Surgery and Enhanced Recovery After 1.8 Person-centred care
Surgery (ERAS) 1.9 Summary
1.4 Low rectal cancer

being considered for tailored multimodal therapy, based

1 Introduction
on molecular biology and pharmaceutical advances.
The ACPGBI has been at the forefront in developing In the UK, through the NCRI Colorectal Cancer
guidelines, position statements and national training Clinical Trials Group and numerous other research
programs related to both common, and complex, col- organizations, we are proud of our record of being at
orectal pathology. These initiatives often serve as a glo- the forefront of designing and completing many inter-
bal reference in this challenging field. The Association nationally acclaimed oncological and surgical trials.
of Coloproctology of Great Britain and Ireland These have been instrumental in shaping our current
(ACPGBI) 2007 Colorectal Cancer Management clinical practice. We must continue to build on this
Guidelines have been the basis for continuous evolution foundation by developing and recruiting into new trials
in the way these cancers are managed. The current to further improve treatment.
update aims to clarify many recent developments on the
multidisciplinary management of colorectal cancer and 1.1 Multidisciplinary teams
to provide links to relevant publications. The recom-
mendations made within these guidelines have been Over the last few decades, multidisciplinary teams (MDTs)
graded according to the Oxford Centre for Evidence- have evolved, and consolidated, in individual units to
based Medicine – levels of evidence (www.cebm.net/ manage colorectal cancer. At the MDT meeting, the clini-
oxford-centre-evidence-based-medicine-levels-evidence- cal nurse specialist, with the attending surgeon, are best
march-2009/). We hope that these guidelines will offer positioned to act as the patients’ advocates and ensure cru-
a framework for clinicians and MDT’s to tailor treat- cial decisions are made with a first-hand knowledge of the
ments to suit individual patients. We also hope to direct patient and their wishes. It is pertinent that MDT recom-
future research and debate in a rapidly evolving field. mendations are based on the available information and
A substantial part of the workload of colorectal units recommendations may, or may not be appropriate, or
is to not only exclude diagnosis of cancer but to man- acceptable to the individual patient. Clinicians should
age cancer of the colon, rectum and anal canal. Access support patients requesting second opinions and guide
to information through technology, and particularly the them with appropriate pathways. Current MDTs should
internet, has changed perceptions and expectations of look to extend their role in training junior surgeons, radi-
cancer patients, their carers and clinicians. The general ologists, histopathologists and oncologists, and mentor-
public and healthcare providers continue to shift focus ing new members of the core team. Personal-audits and
towards cancer prevention and early diagnosis. At the regular feedback between core members should be an
other end of the spectrum, patients with locally integral part of the development of the MDT.
advanced, recurrent or metastatic cancer are increasingly Ongoing sub-specialization has encouraged develop-
ment of specialist MDTs in a number of areas including
anal cancer, early rectal cancer, ‘beyond’-TME and
Correspondence to: Dr Ian Geh, Queen Elizabeth Hospital, Birmingham, UK.
recurrent pelvic cancers, and cytoreductive surgery.
E-mail: [email protected]

6 Colorectal Disease ª 2017 The Association of Coloproctology of Great Britain and Ireland. 19 (Suppl. 1), 6–8
B. Moran et al. Guidelines

Teams treating colorectal disease need to recognize the and NHS England, providing training to MDTs on the
spectrum of disease, diversity of treatments and develop overall management of cancers arising at, or below, the
care pathways to access specialist MDT’s. level of the insertion of the levator muscles, including
the appropriate use of extralevator abdominoperineal
excision (ELAPE). The longer-term oncological out-
1.2 Prevention and earlier diagnosis
comes and the associated morbidity of this initiative are
Public awareness campaigns and the NHS Bowel Cancer yet to be reported.
Screening Program have impacted positively on the
diagnosis of early stage disease, and polyp detection and
1.5 Radiology and Histopathology
clearance are likely to reduce colorectal cancer inci-
dence. Introduction of Faecal Immunochemical Test High quality radiology and detailed histopathology
and Bowel Scope Screening will further improve the reporting is crucial, as it underpins MDT decision
stage at diagnosis of colon and rectal cancer. making. This provides quality assurance to patients
Bowel cancer screening has added to the challenge and clinicians on management decisions. Radiology
of treating polyp cancers and early rectal cancer; onco- and pathology provide valuable prognostic indicators
logical adequacy of minimally invasive interventions in colon and rectal cancer, which helps to determine
(polypectomy and local excisions) vs morbidity and further management. Advances in imaging and use of
mortality risk of resection surgery. The ongoing SPECC biomarkers have initiated individualized treatment
(Significant Polyp Early Colorectal Cancer) Pelican/ strategies to be developed in all stages of disease. We
ACPGBI Program aims to stimulate discussion and predict that these advances will expand exponentially
training in these areas. Robust risk stratification tools to in the next decade.
help MDTs and patients make informed decisions, espe-
cially in an older and frailer population, are needed.
1.6 Chemotherapy and Radiotherapy
Clinical trials, such as the recently completed NCRI
TREC-1 and the new NCRI STAR-TREC in early rec- The use of preoperative radiotherapy, with or without
tal cancer will add to this knowledge. chemotherapy in addition to surgery in ‘operable’ rectal
cancer reduces local recurrence rates, but much of the
published evidence predates modern imaging, making it
1.3 Laparoscopic Surgery and Enhanced Recovery
difficult to quantify the exact benefits. Together with
After Surgery (ERAS)
ongoing improvements in surgical techniques, such as
The Laparoscopic Colorectal Surgery (LAPCO) pro- ELAPE for advanced low rectal cancer, and an increas-
gram, which was a joint initiative between the ACPGBI ing awareness of immediate and long-term toxicity, the
and NHS England, delivered high quality accreditation risk-benefit of using radiotherapy in rectal cancer, either
training in laparoscopic surgery to NHS colorectal sur- to downstage disease or to reduce local recurrence
geons. This initiative, together with increasing public needs careful consideration on an individual basis. There
awareness of laparoscopic surgery, has resulted in a steady remains significant variation in the use of radiotherapy
year-on-year increase in the proportion of cases treated nationally, but with further refinements in imaging and
by minimal access, whilst achieving good oncological expansion of knowledge, this will allow more selective
outcomes in addition to the short-term early benefits, utilization. However the role of optimal surgery remains
particularly in colon cancer but less so in rectal cancer. crucial.
Introduction of ERAS on the background of mini- Further advances in the use of adjuvant chemother-
mally invasive surgery has improved short-term out- apy, with the addition of new targeted agents have
comes including length of stay. Optimal results have failed to materialize. The focus has shifted to earlier use
been reported using a combination of ERAS and mini- of systemic therapy in the neoadjuvant setting for colon
mal access techniques. The concepts from colorectal and rectal cancers, as well as reducing the duration and
surgical ERAS programs have been adopted by other toxicity of adjuvant therapies.
surgical fields and have benefited a wider group of There is increasing worldwide interest in the poten-
patients. tial for non-operative management of rectal cancers of
all stages. Ongoing trials to improve pathological com-
plete response rates (pCR) and translational studies to
1.4 Low Rectal Cancer
develop new predictive markers, together with high-
The Low Rectal Cancer Development (LOREC) pro- quality observational trials such as the NCRI Deferral of
gram is another joint initiative between the ACPGBI Surgery, may allow for safe deferral and hopefully,

Colorectal Disease ª 2017 The Association of Coloproctology of Great Britain and Ireland. 19 (Suppl. 1), 6–8 7
Guidelines B. Moran et al.

complete avoidance of surgery in selected patients who unpredictable, as are many of the acute and late toxici-
have potentially achieved pCR after preoperative ties. These uncertainties should be openly discussed and
chemoradiotherapy (CRT). patients should be able to make informed choices about
their care, in partnership with their healthcare profes-
sionals. These decisions should be subject to regular
1.7 Outcomes and Survivorship
review at appropriate key points during treatment, to
The National Bowel Cancer Audit (NBOCA) has accommodate any changes in circumstances and to
evolved from being a voluntary audit when first allow the patient the opportunity for further discussion
launched in 2000, to currently being a quality assurance or reconsideration.
tool for individual surgeons and NHS Trusts. Although Healthcare professionals must not underestimate the
it has provided invaluable data to drive up the standards psychological and social impact of a diagnosis of col-
of care delivered nationally, there remain opportunities orectal cancer on the individual as well as family, carers
to further improve the quality of data collected. and supporters. There is wide variation in their reac-
Through NBOCA, the publication of individual col- tions, their ability to cope and their recall of informa-
orectal surgeons’ outcomes has empowered patients, by tion received, which may be subject to strong emotions
providing online information about volumes and out- and anxiety. Communication and listening skills for
comes of individual surgeons and NHS Trusts. Individ- such patients need to be exemplary as they form a vital
ual surgeon outcome reporting is contentious and unit part of the patient journey, from undergoing treatment,
data may be more meaningful and is the subject of to recovery and eventual readjustment to life beyond
ongoing discussion. hospital.

1.8 Person-centred care 1.9 Summary

Most importantly, treatment of colorectal cancer should These guidelines offer an updated framework for col-
take into account individual preferences, and be deliv- orectal cancer clinicians and MDTs. They will continue
ered with dignity, compassion and respect. Patients to evolve and require updating in light of ongoing
need to understand that the management of their can- developments and emerging evidence.
cer is individualized and complex. They should be given
an explanation for the perceived delays in commencing
Conflicts of interest
treatment, such as the need for further investigations or
MDT discussion. Response to treatment is often None of the authors have any conflicts to declare.

8 Colorectal Disease ª 2017 The Association of Coloproctology of Great Britain and Ireland. 19 (Suppl. 1), 6–8