Management of Metastatic Colorectal Cancer (mCRC): Real-World Recommendations.

Introduction: Metastatic CRC is considered as a heterogenous disease. Its management is therefore complex and dynamic. In order the give a ready reference to community oncologists, we developed this real world recommendations.

Methods: A group of experts with academic background and real world experience in mCRC got together. We reviewed the current literature and the insights gained from our real world experience. Based on the same we put together these recommendations.

Recommendations Results: Molecular testing should be done wherever possible. Most of these patients will be treated with a palliative approach. Doublet chemotherapy is a long-standing standard of care. Triplet therapy may be offered where a more aggressive approach is indicated. Combination with anti -vascular endothelial growth factor antibodies and/or anti EGFR antibodies is also considered standard. In the first-line setting, pembrolizumab can be used for patients with mCRC and microsatellite instability-high or deficient mismatch repair tumours; Left and right sided tumours are distinct entities. Combination of chemotherapy and targeted therapy is used as per individual patient and tumour characteristics.Oligometastatic disease can be approached with potentially curative intent. Cytoreductive surgery plus chemotherapy can be offered to selected patients with peritoneal only metastases. Stereotactic body radiation therapy can be used as local therapy for patients with oligometastatic liver only disease who cannot be taken up for surgery. New strategies include induction-maintenance chemotherapy and perioperative chemotherapy. All drugs/ regimen included as standard of care in the first line can also be used in subsequent lines. Specific targetable driver mutation tumours can be treated accordingly with their complementary biological therapy.

Conclusion: Multidisciplinary team management and shared decision making are possible when patient and caregivers choose to become active participants.