Colorectal cancer

Key NICE recommendations on management

Refer to the full NICE guideline and your local drug formulary for further information when prescribing – including dose, contraindications, cautions, safety issues, adverse effects, drug interactions, and monitoring requirements. Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is 'off-label').

Management of local disease

For people presenting with acute left-sided large bowel obstruction:

• Either stenting or emergency surgery should be offered if potentially curative treatment is suitable for them

• Stenting should be considered if they are going to be treated with palliative intent.

For people with early rectal cancer (cT1-T2, cN0, M0):

• Preoperative radiotherapy should only be offered as part of a clinical trial

• One of the following treatments should be offered after discussion with the person:

  • Transanal excision (including transanal minimally invasive surgery and transanal endoscopic microsurgery)

  • Endoscopic submucosal dissection

  • Total mesorectal excision.

For people with rectal cancer that is cT1-T2, cN1-N2, M0, or cT3-T4, any cN, M0, the following should be offered:

• Preoperative radiotherapy or chemoradiotherapy

• Surgery (if they have a resectable tumour).

For people with locally advanced primary or recurrent rectal cancer that might potentially need multi-visceral or beyond total mesorectal excision surgery, referral to a specialist centre to discuss exenterative surgery should be considered.

For people with colon cancer:

• Preoperative systemic anticancer therapy should be considered for cT4 colon cancer

• Laparoscopic resection is recommended as an alternative to open resection for treating colon cancer when both techniques are considered suitable.

For people with stage 3 rectal cancer (pT1-T4, pN1-N2, M0) treated with short-course radiotherapy or no preoperative treatment, or stage 3 colon cancer (pT1-T4, pN1-N2, M0):

• 3 months of capecitabine in combination with oxaliplatin (CAPOX) should be offered. If this is not suitable, one of the following should be offered:

  • 3 to 6 months of oxaliplatin in combination with 5-fluorouracil and folinic acid (FOLFOX)

  • 6 months of single-agent fluoropyrimidine (e.g., capecitabine).

  The choice of adjuvant systemic anticancer therapy should be based on the person’s histopathology, performance status, preferences, any comorbidities and age.

Management of advanced or metastatic colorectal cancer

All people with metastatic colorectal cancer suitable for systemic anticancer therapy should be tested for RAS and BRAF V600E mutations to guide therapy.

See the NICE guideline for information on systemic anticancer therapy options for advanced or metastatic colorectal cancer.

For people with incurable metastatic colorectal cancer who are receiving systemic anticancer therapy and have an asymptomatic primary tumour, surgical resection of the primary tumour should be considered.

For people with colorectal cancer metastases:

• In the liver

  • Resection (either simultaneous or sequential), perioperative systemic anticancer therapy (if liver resection is suitable), and chemotherapy with local ablative techniques (for people with colorectal liver metastases that are unsuitable for liver resection) should be considered

  • Selective internal radiation therapy should not be offered as first-line treatment for people with colorectal liver metastases that are unsuitable for local treatment

• In the lung

  • Metastasectomy, ablation or stereotactic body radiation therapy should be considered for people with lung metastases that are suitable for local treatment

  • Biopsy should be considered for people with a single lung lesion to exclude primary lung cancer

• Limited to the peritoneum

  • Systemic anticancer therapy should be offered, and a multidisciplinary team should discuss referral to a nationally commissioned specialist centre.

Ongoing care and support

For people who have had potentially curative surgical treatment for non-metastatic colorectal cancer, follow-up for detection of local recurrence and distant metastases should be offered for the first 3 years. Follow-up should include serum carcinoembryonic antigen and CT scan of the chest, abdomen and pelvis.

People who will potentially have sphincter-preserving surgery should be given information on low anterior resection syndrome (LARS) and be advised to seek help from primary care if they think they have symptoms of LARS, such as:

• Increased frequency of stool

• Urgency with or without incontinence of stool

• Feeling of incomplete emptying of the bowels

• Fragmentation of stool (passing small amounts little and often)

• Difficulty in differentiating between gas and stool.

Assess people with symptoms of LARS using a validated patient-administered questionnaire (e.g., the LARS score).

Offer treatment (e.g., dietary management, laxatives, anti-bulking agents, anti-diarrhoeal agents, or anti-spasmodic agents) in primary care to people with bowel dysfunction symptoms associated with LARS. Seek secondary care advice if treatment is not successful.

Prevention of colorectal cancer

To reduce the risk of colorectal cancer in people with Lynch syndrome, aspirin should be considered.

© NICE (2017) (2021) (2025) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.