General

Guideline Title

Role of endoscopy in the staging and management of colorectal cancer.

Bibliographic Source(s)

ASGE Standards of Practice Committee, Fisher DA, Shergill AK, Early DS, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, Evans JA, Fanelli RD, Foley KQ, Fonkalsrud L, Hwang JH, Jue T, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Sharaf R, Cash BD. Role of endoscopy in the staging and management of colorectal cancer. Gastrointest Endosc. 2013 Jul;78(1):8-12. [51 references] PubMed

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Davila RE, Rajan E, Adler D, Hirota WK, Jacobson BC, Leighton JA, Qureshi W, Zuckerman MJ, Fanelli R, Hambrick D, Baron TH, Faigel DO. ASGE guideline: the role of endoscopy in the diagnosis, staging, and management of colorectal cancer. Gastrointest Endosc. 2005 Jan;61(1):1-7.

Recommendations

Major Recommendations

Definitions for the quality of the evidence (++++, +++O, ++OO, and +OOO) and for the strength of the recommendations (“recommends” or “suggests”) are provided at the end of the “Major Recommendations” field.

Recommendations

The Practice Committee recommends removal of suspected neoplastic lesions at the time of colonoscopy when not contraindicated and as technical expertise allows. (++++)
The Practice Committee recommends endoscopic ultrasound (EUS) in the preoperative locoregional staging of colorectal cancer (CRC) to guide therapy. (+++O)
The Practice Committee recommends weighing the risk of recurrence against the individual’s operative risk in all cases in which surgery is being considered as a treatment for CRC. (+++O)
The Practice Committee recommends surgical management of all malignant polyps with unfavorable histological features if the patient is an appropriate surgical candidate. (+++O)
The Practice Committee recommends that pedunculated polyps found to contain cancer confined to the submucosa of the polyp or stalk and with favorable histological features be managed endoscopically. (+++O)
The Practice Committee recommends surgery for sessile or flat colonic neoplasia that demonstrates submucosal invasion if the patient is an appropriate surgical candidate. (+++O)
The Practice Committee suggests surgical management for sessile or flat colonic neoplasia that is determined to be malignant after piecemeal endoscopic resection if the patient is an appropriate surgical candidate. (++OO)
The Practice Committee recommends endoscopic mucosal resection (EMR) only be attempted if complete resection of neoplastic lesions is anticipated. (+++O)

Definitions:

Grading of Recommendations, Assessment, Development and Evaluation (GRADE) System for Rating the Quality of Evidence for Guidelines

Quality of Evidence	Definition	Symbol
High quality	Further research is very unlikely to change confidence in the estimate of effect.	++++
Moderate quality	Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.	+++O
Low quality	Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.	++OO
Very low quality	Any estimate of effect is very uncertain.	+OOO

Adapted from Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6.

Recommendation Strength

The strength of individual recommendations is based on both the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as “the Practice Committee suggests,” whereas stronger recommendations are typically stated as “the Practice Committee recommends.”

Clinical Algorithm(s)

None provided

Scope

Disease/Condition(s)

Colorectal cancer (CRC)

Guideline Category

Evaluation
Management
Risk Assessment
Treatment

Clinical Specialty

Colon and Rectal Surgery
Gastroenterology
Oncology
Radiology

Intended Users

Physicians

Guideline Objective(s)

To provide information on the role of endoscopy in the staging and treatment of colorectal cancer (CRC)

Target Population

Patients with suspected or confirmed colorectal cancer (CRC)

Interventions and Practices Considered

Removal of suspected neoplastic lesions at the time of colonoscopy
Endoscopic ultrasound (EUS) in the preoperative locoregional staging of colorectal cancer (CRC) to guide therapy
Weighing the risk of recurrence against operative risk
Endoscopic versus surgical management based on histological features of polyps
Use of endoscopic mucosal resection (EMR) for complete resection of neoplastic lesions

Major Outcomes Considered

Sensitivity, specificity, and accuracy of diagnostic tests
Success rate of endoscopic procedures
Adverse events associated with endoscopic procedures
Recurrence rate
Risk of lymph node metastasis

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

In preparing this guideline, a search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When limited or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts.

The time frame for all searches was January 1990 to January 2013.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Grading of Recommendations, Assessment, Development and Evaluation (GRADE) System for Rating the Quality of Evidence for Guidelines

Quality of Evidence	Definition	Symbol
High quality	Further research is very unlikely to change confidence in the estimate of effect.	++++
Moderate quality	Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.	+++O
Low quality	Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.	++OO
Very low quality	Any estimate of effect is very uncertain.	+OOO

Adapted from Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time that the guidelines are drafted.

Rating Scheme for the Strength of the Recommendations

Recommendation Strength

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Internal Peer Review

Description of Method of Guideline Validation

This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the “Major Recommendations” field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate use of endoscopy in the staging and management of colorectal cancer (CRC)

Potential Harms

The major adverse events associated with colonic self-expandable metal stents (SEMS) placement include obstruction, migration, and perforation. Dilation after colonic SEMS placement should be avoided because of the associated risk of perforation.
In all cases of potential surgical referral, the risk of recurrent disease should be weighed against the operative risk in individual patients.
The major adverse events for endoscopic mucosal resection (EMR) and endoscopic submucosal resection (ESR) are the same as those for standard polypectomy (i.e., bleeding and perforation); however, the rate is higher.

Qualifying Statements

Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time that the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice.
This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Foreign Language Translations
Patient Resources

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness

Identifying Information and Availability

Bibliographic Source(s)

ASGE Standards of Practice Committee, Fisher DA, Shergill AK, Early DS, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, Evans JA, Fanelli RD, Foley KQ, Fonkalsrud L, Hwang JH, Jue T, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Sharaf R, Cash BD. Role of endoscopy in the staging and management of colorectal cancer. Gastrointest Endosc. 2013 Jul;78(1):8-12. [51 references] PubMed

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2005 Jan (revised 2013 Jul)

Guideline Developer(s)

American Society for Gastrointestinal Endoscopy - Medical Specialty Society

Source(s) of Funding

American Society for Gastrointestinal Endoscopy

Guideline Committee

Standards of Practice Committee

Composition of Group That Authored the Guideline

Committee Members : Deborah A. Fisher, MD; Amandeep K. Shergill, MD; Dayna S. Early, MD; Ruben D. Acosta, MD; Vinay Chandrasekhara, MD; Krishnavel V. Chathadi, MD; G. Anton Decker, MD; John A. Evans, MD; Robert D. Fanelli, MD, SAGES Representative; Kimberly Q. Foley, RN, SGNA Representative; Lisa Fonkalsrud, RN, SGNA Representative; Joo Ha Hwang, MD; Terry Jue, MD; Mouen A. Khashab, MD; Jenifer R. Lightdale, MD; V. Raman Muthusamy, MD; Shabana F. Pasha, MD; John R. Saltzman, MD; Ravi Sharaf, MD; Brooks D. Cash, MD ( Chair )

Financial Disclosures/Conflicts of Interest

The following authors disclosed financial relationships relevant to this publication: Dr Fisher, consultant to Epigenomics Inc; Dr Hwang, on the speakers’ bureau of Novartis, consultant to U.S. Endoscopy, and received a grant from Olympus; Dr Fanelli, owner/director of New Wave Surgical and on the advisory board of Via Surgical; Dr Khashab, consultant to, receives honoraria from, and on the advisory board of Boston Scientific; Dr Chathadi, on the speakers’ bureau of Boston Scientific; Dr Muthusamy, consultant to Boston Scientific. The other authors disclosed no financial relationships relevant to this publication.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Available from the American Society for Gastrointestinal Endoscopy (ASGE) Web site.

Availability of Companion Documents

None available

Patient Resources

The following are available:

Myths about colorectal cancer. Patient education video. Oak Brook (IL): American Society for Gastrointestinal Endoscopy (ASGE).
What to expect from your colonoscopy procedure. Patient education video. Oak Brook (IL): American Society for Gastrointestinal Endoscopy (ASGE).

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline’s content.

NGC Status

This NGC summary was completed by ECRI on March 23, 2005. The information was verified by the guideline developer on March 31, 2005. This summary was updated by ECRI Institute on September 25, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer’s copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria.

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.