Stage II

MSI High

MSI Low or MSI Stable

Observe

Additional High Risk Factors Present?

Colon Cancer

Updated: 2017-07-28

NO

YES

CH CR 1: FOLFOX (preferred)
CH CR 2: 5FU/LV
CH CR 3: Capecitabine
CH CR 4: CapeOx

Stage II patients will be evaluated for risk of recurrence.
(Recommend review by a second pathologist)
Indicators of high risk include:
• T4 (stage IIB/IIC)
• Poor differentiation / High grade
• • Bowel obstruction
• Lesions with localized perforation
• Close, indeterminate, or positive margins
• lymphovascular invasion
• signet-ring cell features
• oncotype/gene expression signature tests

COMMENTS from Pathway Team

Stage III

Colon Cancer

Updated: 2017-07-28

CH CR 1: FOLFOX
CH CR 2: 5FU/LV
CH CR 3: Capecitabine
CH CR 4: CapeOx

COMMENTS from Pathway Team

Stage III: Per recent ASCO data, for low-risk Stage III patients, patients may be treated with 3 cycles (6 doses) instead of 6 cycles (12 doses).

Stage IV, PS 0-1

Colon Cancer

Updated: 2017-07-28

CH CR 1/6: FOLFOX +/- bev
CH CR 4/7: CapeOx +/- bev
CH CR 10: 5FU/LV + bev
CH CR 11: Cape + bev
CH CR 12: FOLFOXIRI
CH CR 8/9: FOLFIRI +/- bev

CH CR 8/9: FOLFIRI +/- bev
CH CR 20: FOLFIRI + aflibercept
CH CR 21: Irinotecan

CH CR 28: Regorafenib
CH CR 30: Trifluridine + tipiracil

Best supportive care

CH CR 1/6: FOLFOX +/- bev
CH CR 4/7: CapeOx +/- bev
CH CR 10: 5FU/LV + bev
CH CR 11: Cape + bev
CH CR 12: FOLFOXIRI
CH CR 8/9: FOLFIRI +/- bev
CH CR 14: FOLFOX + cetuximab
CH CR 15 FOLFOX + panitumumab
CH CR 16: CapeOx + cetuximab
CH CR 17 CapeOx + panitumumab

CH CR 28: Regorafenib
CH CR 30: Trifluridine + tipiracil

Best supportive care

COMMENTS from Pathway Team

Stage IV: Regimens containing cetuximab and panitumumab should only be given to patients who have undergone RAS testing (KRAS and NRAS required), and who are wild type (WT) for all RAS genes tested.

KRAS Mutated

KRAS Wildtype

Stage IV, PS 3-4

Colon Cancer

Updated: 2017-07-28

CH CR 1: FOLFOX
CH CR 4: CapeOx
CH CR 8/9: FOLFIRI +/- bev
CH CR 20: FOLFIRI + aflibercept
CH CR 21: Irinotecan

CH CR 18: FOLFIRI + cetuximab
CH CR 25: Irinotecan + cetuximab
CH CR 29: Irinotecan + panitumumab
CH CR 26: Cetuximab
CH CR 27: Panitumumab

CH CR 2/10: 5FU/LV +/- bev
CH CR 11: Capecitabine +/- bev

CH CR 28: Regorafenib
CH CR 30: Trifluridine + tipiracil

CH CR 1: FOLFOX
CH CR 4: CapeOx
CH CR 28: Regorafenib
CH CR 30: Trifluridine + tipiracil

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COMMENTS from Pathway Team

Stage IV: Regimens containing cetuximab and panitumumab should only be given to patients who have undergone RAS testing (KRAS and NRAS required), and who are wild type (WT) for all RAS genes tested.

PS 3

Improved PS?

PS 4

YES

NO

Best Supportive Care

KRAS Mutated

KRAS Wildtype