Colorectal cancer
Also known as: colon cancer · CRC · rectal cancer
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Treatment of Metastatic Colorectal Cancer: ASCO Guideline
ASCO · 2022
The American Society of Clinical Oncology's recommendations for treating colorectal cancer that has spread beyond the bowel. It covers what systemic therapy to start with when the disease cannot be removed surgically, how to approach patients whose liver metastases might still be resected, and when local treatments such as stereotactic radiotherapy or cytoreductive surgery are worth adding.
- For previously untreated disease that cannot be resected, two-drug chemotherapy is the standard offer, with a three-drug regimen an option in selected fitter patients. source
- Patients whose liver metastases may be removed with curative intent should be offered either chemotherapy around the operation or surgery on its own. source
- Stereotactic body radiotherapy is an option after systemic therapy for limited liver-only disease in patients who are not surgical candidates. source
- Cytoreductive surgery plus systemic chemotherapy may be considered for selected peritoneal metastases, but adding heated intraperitoneal chemotherapy is explicitly not recommended. source
Metastatic colorectal cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up
ESMO · 2026
Supersedes the 2023 European Society for Medical Oncology (ESMO) version
The European Society for Medical Oncology's current guidance on colorectal cancer that has spread. It spans diagnosis, molecular characterisation of the tumour, staging, local and systemic treatment, and follow-up, and was written by a multidisciplinary panel drawn from European and Asian centres. It replaces the society's 2023 version and leans heavily on molecular profiling to direct treatment choice and sequencing.
- Molecular characterisation of the tumour is treated as a routine part of the diagnostic work-up, not an optional extra, and drives treatment selection. source
- Recommendations cover the full pathway — diagnosis, staging, local treatment, systemic treatment and follow-up — rather than drug therapy alone. source
- Locoregional procedures sit alongside chemotherapy and targeted agents as part of a multidisciplinary treatment plan. source
- Published in Annals of Oncology 2026;37(6):759-776 as the successor to the 2023 ESMO metastatic colorectal cancer guideline. source
US vs EU key differences
- First-line immunotherapy for MSI-high or mismatch-repair-deficient disease has diverged: ASCO recommends pembrolizumab, while the newer ESMO guideline prefers dual checkpoint blockade with nivolumab plus ipilimumab and relegates pembrolizumab to an alternative. source
- BRAF V600E disease is treated at different points in the pathway: ASCO recommends encorafenib plus cetuximab for previously treated patients, whereas ESMO moves targeted therapy into the first line with FOLFOX plus encorafenib and cetuximab. source
- The two guidelines agree on the sidedness rule for microsatellite-stable RAS wild-type tumours: chemotherapy plus an anti-EGFR antibody for left-sided primaries and a bevacizumab or anti-VEGF-based regimen for right-sided primaries. source
- A four-year publication gap shows in the later-line menu: ESMO sets out trifluridine-tipiracil with or without bevacizumab, regorafenib or fruquintinib, and targeted options for HER2-amplified, KRAS G12C and NTRK or RET fusion tumours, a refractory-setting landscape that had not yet consolidated when ASCO published in 2022. source
- ASCO takes explicit positions on local therapies that shape US practice, considering stereotactic body radiotherapy for unresectable liver oligometastases, advising against routine selective internal radiation therapy, and not recommending hyperthermic intraperitoneal chemotherapy alongside cytoreductive surgery. source
What changed recently
- EU2023 → 20262026-04-14
ESMO replaced its 2023 metastatic colorectal cancer guideline with the 2026 edition (Cremolini et al., Ann Oncol 37(6):759-776); the 2023 document is now marked superseded in this atlas.
See the full update feed for changes across every system.