Screening and diagnosis

Classification and risk stratification

Perioperative care

Quality improvement

Patient education

Nonpharmacologic interventions

Therapeutic procedures

Respiratory support

Follow-up and surveillance

Specific circumstances

Preventative measures

Medical management

Surgical interventions

Inpatient care

Diagnostic procedures

Diagnostic investigations

Insufficient evidence to make a recommendation.

Strongly favor this test or intervention.

The Fong clinical risk score is a tool used to assess the risk of hepatic resection in patients with metastatic colorectal cancer by analyzing five specific medical factors. These factors are evaluated as true or false, and each true condition adds one point to the total score, which ranges from 0 to 5. The factors considered are:

- Node-positive primary
- Disease-free interval less than 12 months from diagnosis of the primary tumor to the appearance of metastasis
- More than one hepatic tumor present
- Preoperative carcinoembryonic antigen (CEA) level greater than 200 ng/mL
- Largest hepatic tumor greater than 5 cm

Each of these factors is assigned a score of 1 if present. By summing up the scores for all factors marked true, a total score is calculated. This total is then used to interpret survival probabilities over 1-year and 5-year timeframes, offering insights into the patient's prognosis and aiding in clinical decision-making.

Here's how the interpretations align with the scores:

| Score | Probability of 1-year survival | Probability of 5-year survival |
|-------|-------------------------------|---------------------------------|
| 0     | 93%                           | 60%                             |
| 1     | 91%                           | 44%                             |
| 2     | 89%                           | 40%                             |
| 3     | 86%                           | 20%                             |
| 4     | 70%                           | 25%                             |
| 5     | 71%                           | 14%                             |

In summary, the score reflects the cumulative impact of these risk factors, directly correlating to survival probabilities, and serves as a valuable tool in planning the treatment strategy for metastatic colorectal cancer., and serves as a valuable tool in planning the treatment strategy for metastatic colorectal cancer.

The Fong Clinical Risk Score is a prognostic tool specifically designed for patients with metastatic colorectal cancer who are undergoing hepatic resection. This scoring system is used to predict the survival outcome after the surgical procedure. It takes into account seven preoperative factors: node-positive primary, disease-free interval from primary to metastases of less than 12 months, more than one hepatic tumor, largest hepatic tumor greater than 5 cm, carcinoembryonic antigen level greater than 200 ng/mL, and presence of extrahepatic disease. Each factor is assigned one point, and the total score ranges from 0 to 5, with higher scores indicating a worse prognosis. The Fong Clinical Risk Score does not have specific exclusion criteria, but it may not be applicable or accurate in patients with other types of cancer or in those who are not candidates for hepatic resection.

Fong clinical risk score for hepatic resection in metastatic colorectal cancer

The TNM (Tumor, Node, Metastasis) classification system for colorectal cancer provides a structured way to determine the stage of cancer based on three key parameters: the extent of the primary tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The system collects these inputs from predefined categories to compute the cancer stage.

For tumor classification, the options indicate the level of tumor invasion: 
- Tx means the primary tumor cannot be assessed.
- T0 indicates no evidence of a primary tumor.
- Tis designates carcinoma in situ.
- T1 to T4b describe increasing levels of invasion, from submucosa (T1) to adherence to adjacent structures (T4b).

Lymph node classification consists of:
- Nx indicates that regional lymph nodes cannot be assessed.
- N0 signifies no regional lymph node metastasis.
- N1a to N2b describe the number of positive regional lymph nodes or presence of tumor deposits, from N1a (1 positive node) to N2b (7 or more positive nodes).

Metastasis classification includes:
- M0 for no distant metastasis.
- M1a to M1c, describing the extent and location of metastases, from one site (M1a) to peritoneal metastasis (M1c).

The computation involves checking the specific boolean conditions for each classification and determines the result by matching these conditions to predefined stage assignments:

1. Stage 0 is indicated if tumor is Tis, with no lymph node or distant metastasis (N0, M0).
2. Stage I corresponds to a T1 or T2 tumor with no lymph node or distant metastasis (N0, M0).
3. Stage II sub-stages are assigned based on:
   - IIA: Tumor T3 with N0 and M0.
   - IIB: Tumor T4a with N0 and M0.
   - IIC: Tumor T4b with N0 and M0.
4. Stage III is assessed by various combinations of tumor T1-T4b with positive lymph nodes but no distant metastasis, subdivided into IIIA, IIIB, IIIC based on specific combinations of T, N, and M statuses.
5. Stage IV is evaluated when there is any level of T and N, but with distant metastasis present (M1a to M1c), subdivided into IVA, IVB, IVC based on metastasis categorization.

The calculator in question is the TNM Classification for Colorectal Cancer. TNM stands for Tumor, Node, Metastasis, and it is a globally recognized system used for staging different types of cancers, including colorectal cancer. 

This classification system is applicable to patients diagnosed with colorectal cancer. It helps clinicians to determine the extent of cancer spread in the body, which is crucial for planning the most effective treatment strategy and predicting patient prognosis. 

The TNM system classifies cancer based on three key factors: the size and extent of the primary tumor (T), whether the cancer has spread to nearby lymph nodes (N), and the presence of distant metastasis (M). Each factor is assigned a numerical value, with higher numbers indicating more advanced disease.

There are no specific exclusion criteria for the use of the TNM classification for colorectal cancer. However, it is less useful in early-stage cancers where the disease is localized and has not spread to lymph nodes or distant organs. It is also less applicable in patients with rare forms of colorectal cancer, such as neuroendocrine tumors, as these may behave differently from common adenocarcinomas.

TNM classification for colorectal cancer

The Karnofsky Performance Scale (KPS) provides a practical method to evaluate a patient's functional ability and the extent of care required based on their health status. The scale ranges from 0% to 100%, where higher percentages signify better functional capacity and health.

This tool involves selecting a descriptive statement that best reflects a patient's current condition from a predefined list. Each statement is connected to a specific KPS percentage that indicates the patient’s ability to perform daily activities and their dependency levels. Here’s how the assessment works:

- When a patient is described as "Normal, no complaints, no evidence of disease," this is assessed as KPS 100%. At this level, the individual can engage in all regular activities, including work, without needing special care.

- If a patient can "carry on normal activity" but exhibits "minor signs or symptoms of disease," they are scored at KPS 90%, indicating the capability to maintain routine activities without requiring special care.

- A description of "Normal activity with effort, some signs or symptoms of disease" aligns with KPS 80%. This suggests the patient can still carry out normal activities but might require some extra effort.

- When the condition reflects "Cares for self, unable to carry on normal activity or to do active work," it corresponds to KPS 70%. The patient can handle most personal needs independently but may need occasional assistance.

- "Requires occasional assistance but is able to care for most personal needs" is rated as KPS 60%, implying increased dependency on assistance though the patient remains mostly self-sufficient.

- At KPS 50%, for conditions described as "Requires considerable assistance and frequent medical care," the patient can live at home but needs considerable help with personal care.

- As the need for care intensifies, with descriptions like "Disabled, requires special care and assistance," the KPS drops to 40%. This marks a significant deterioration in self-care ability.

- "Severely disabled, hospital admission is indicated, death not imminent" corresponds to KPS 30%, highlighting a need for hospitalization without immediate life-threatening conditions.

- For those "Very sick," necessitating hospital admission and "active supportive treatment," the KPS is 20%, indicating critical care requirements.

- At KPS 10%, "Moribund" denotes an inability to care for oneself, with urgent need for hospital-level care and a poor prognosis.

- Lastly, "Dead" is considered as KPS 0%.

This scale is instrumental in providing a quick overview of a patient's ability to function independently and their need for medical support, thereby facilitating better care planning and resource allocation.

The Karnofsky Performance Status Scale (KPSS) is a clinical calculator used primarily in patients with cancer. It is a simple, numerical scale that measures a patient's functional status, ability to perform daily activities, and overall quality of life. The KPSS ranges from 0 (indicating death) to 100 (indicating perfect health). 

The clinical utility of the KPSS is to assess a patient's prognosis, determine appropriate treatment strategies, and monitor changes in a patient's condition over time. It is particularly useful in oncology for determining eligibility for certain treatments, such as chemotherapy or surgery, and for predicting survival outcomes. 

There are no specific exclusion criteria for the use of the KPSS. However, it is less useful in patients with non-cancer illnesses or in those with cognitive impairment who may not be able to accurately self-report their functional status.

Karnofsky Performance Scale

The Eastern Cooperative Oncology Group (ECOG) performance status calculator is designed to evaluate a patient's functional ability and categorize it into a specific score from 0 to 5. This quantitative measure helps clinicians make informed decisions about treatment based on the patient's capacity for daily activities and self-care. Here's how it operates:

The user provides input by selecting the description that best matches the patient's current condition from a list of predefined options. These options encapsulate various levels of activity and ability:

- A patient who is "Fully active, able to carry on all pre-disease performance without restriction" is assigned a score of ECOG PS 0. This indicates that the patient is not limited in any capacity by their disease.
- If a patient is "Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, such as light housework, office work," they receive an ECOG PS 1. This means the patient can perform some self-care and work activities but faces restrictions with strenuous tasks.
- "Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours" corresponds to an ECOG PS 2. This reflects moderate impairment, where the patient is active for the majority of the day but not capable of work activities.
- A patient who is "Capable of only limited self-care, confined to bed or chair more than 50% of waking hours" gets an ECOG PS 3. This score denotes significant limitation, as the patient is mobile for less than 50% of the time and requires assistance for most activities.
- With "Completely disabled, cannot carry on any self-care, totally confined to bed or chair," the patient is categorized as ECOG PS 4, indicating severe impairment and complete dependency.
- Finally, if the patient is "Dead," they are assigned an ECOG PS 5.

These score assignments help standardize assessments, providing an objective measure of a patient's status which can be pivotal in guiding medical decisions and evaluating treatment options.

The Eastern Cooperative Oncology Group (ECOG) performance status, also known as the ECOG score, is a widely used tool in oncology to assess a patient's level of functioning in terms of their ability to care for themselves, daily activity, and physical ability (walking, working, etc.). It is applicable to patients with cancer of any type and at any stage.

The ECOG score ranges from 0 to 5, with 0 indicating fully active and able to carry on all pre-disease activities without restriction, and 5 indicating death. The score is used to determine a patient's prognosis, assess how a disease is progressing, and to determine appropriate treatment strategies. It is also often used in clinical trials to assess eligibility and to monitor patient progress.

There are no specific exclusion criteria for the use of the ECOG score, but it is important to note that it is a subjective measure and may not fully capture a patient's functional status. It is also less useful in patients with fluctuating or rapidly changing conditions.

Eastern Cooperative Oncology Group performance status (ECOG score)

The Modified Glasgow Prognostic Score (mGPS) is a key tool in predicting cancer outcomes, relying on the assessment of two biochemical markers: C-reactive protein (CRP) and albumin. This score helps to categorize the prognosis into three levels: good, intermediate, and poor.

To compute the mGPS:

- C-reactive protein is evaluated first. Two options are considered:  
  - If the CRP is less than or equal to 10 mg/L, it indicates lower systemic inflammation.
  - If the CRP is greater than 10 mg/L, it signifies higher inflammation levels.

- Albumin is the second marker, with two possibilities:  
  - An albumin level of less than 3.5 g/dL [35 g/L] suggests malnutrition or potential inflammatory conditions.
  - An albumin level equal to or greater than 3.5 g/dL [35 g/L] signifies a normal nutritional status and protein reserves.

The mGPS score is derived based on the following systematic interpretation:

- If CRP is <= 10 mg/L, regardless of the albumin level, the score is mGPS 0, corresponding to a good prognosis. This combination indicates a low level of inflammation, which is a favorable signal in cancer outcomes.
 
- If CRP is > 10 mg/L and albumin is >= 3.5 g/dL [35 g/L], the score is mGPS 1, associated with an intermediate prognosis. This combination suggests elevated inflammation yet with sufficient nutritional status, resulting in a moderate outlook.

- If CRP is > 10 mg/L and albumin is < 3.5 g/dL [35 g/L], the result is mGPS 2, indicating a poor prognosis. This reflects high inflammation levels coupled with low albumin, suggesting a more severe condition.

Here's a concise summary table for reference:

| C-reactive Protein | Albumin               | mGPS Score | Interpretation          |
|---------------------|-----------------------|-------------|-----------------------|
| <= 10 mg/L          | < 3.5 or >= 3.5 g/dL  | 0           | Good prognosis         |
| > 10 mg/L           | >= 3.5 g/dL           | 1           | Intermediate prognosis |
| > 10 mg/L           | < 3.5 g/dL            | 2           | Poor prognosis         |

This systematic approach enables healthcare providers to improve risk stratification in cancer patients, allowing for more tailored treatment planning.

The Modified Glasgow Prognostic Score (mGPS) is a clinical calculator used in the field of oncology to predict the prognosis of patients with cancer. It is applicable to a wide range of cancer types and stages, making it a versatile tool for clinicians. The mGPS is based on two simple, routinely measured inflammatory markers: C-reactive protein (CRP) and albumin levels. 

The clinical utility of the mGPS lies in its ability to stratify patients into different risk groups based on their inflammatory response to cancer. This can guide clinicians in making decisions about treatment strategies and follow-up plans. It can also provide valuable prognostic information to patients and their families.

There are no specific exclusion criteria for the use of the mGPS. However, it should be noted that the score may not be as accurate in patients with concurrent inflammatory or infectious conditions, as these can also affect CRP and albumin levels. Additionally, the mGPS may not be applicable to patients with rare types of cancer or those with very early or very advanced disease, as it has not been extensively validated in these groups.

Modified Glasgow Prognostic Score for cancer outcomes (mGPS)

Colon cancer

Indications for screening

Indications for screening, general population, aged 50-75 years

Indications for testing

Indications for testing (chronic constipation)

Management of metastases

Management of metastases, peritoneal metastases

Surveillance after curative-intent therapy

Surveillance after curative-intent therapy, clinical assessment and laboratory tests

Molecular testing

Molecular testing, dMMR/MSI status

Management of acute complications

Management of acute complications, right-sided colon obstruction

Choice of screening tests

Choice of screening tests, primary choice

History and physical examination

Management of nonmetastatic disease

Management of nonmetastatic disease, adjuvant chemoradiotherapy, stage II

Indications for screening, general population, aged 45-49 years

Aspirin for primary prevention

Management of acute complications (antibiotic therapy)

Management of nonmetastatic disease (recurrence)

Biopsy and histopathology

Biopsy and histopathology, technical considerations

Indications for testing (lower gastrointestinal bleeding)

Surveillance after curative-intent therapy, surveillance colonoscopy

Indications for screening, high-risk individuals, IBD

Management of nonmetastatic disease, adjuvant chemoradiotherapy, stage III

Surveillance after curative-intent therapy, surveillance imaging

Technical considerations for surgery

Technical considerations for surgery, preoperative care

Management of metastases, perioperative treatment

Indications for screening, high-risk individuals, family history

Evaluation in emergency settings

Management of metastatic disease

Management of metastatic disease, surgical resection

Management of acute complications, perforation

Indications for screening (risk stratification)

Primary prevention in PSC

Management of metastases, liver metastases

Management of acute complications (unstable patients)

Technical considerations for surgery (postoperative care)

Management of acute complications, left-sided colon obstruction

Management of metastatic disease, systemic therapy, first-line

Molecular testing, DPD deficiency

Primary prevention in diabetes mellitus type 2

Primary prevention in T2DM

Indications for screening, general population, aged 76-85 years

Agents with no evidence for benefit

Management of metastatic disease, systemic therapy, second-line

Surveillance after curative-intent therapy, general principles

Management of nonmetastatic disease, surgical resection

Management of metastatic disease (palliative interventions)

Imaging for staging

Imaging for staging, PET

Management of metastases, lung metastases

Indications for screening, high-risk individuals, PSC

Management of nonmetastatic disease, adjuvant chemoradiotherapy, timing

Imaging for staging, CT/MRI

Technical considerations for surgery (perioperative care)

Choice of screening tests, alternative choices

Laboratory tests

Staging

Indications for screening (high-risk individuals, HHT)

Biopsy and histopathology (general principles)

Indications for screening (high-risk individuals, hereditary cancer syndromes)

Management of acute complications (lower gastrointestinal bleeding)

Management of metastatic disease (systemic therapy, maintenance)

Aspirin for secondary prevention

Management of metastatic disease (systemic therapy, subsequent lines)

Management of nonmetastatic disease (neoadjuvant therapy)

Updated 2024 ESMO guidelines for third and further lines of treatment in advanced colorectal cancer


Colon cancer

Guidelines

Key sources