Appointment sheet
Colorectal cancer
Prepared with OnCo (onco.cc/prep/colorectal/). Orientation, not medical advice; your team knows your case.
My details
Name
Date of appointment
Hospital and clinician
Who is coming with me
What I know, what is unclear, changes to discuss
Saved in this browserWhat I know so far
What is unclear to me
Changes since last time
My questions
54 on the sheetNewly diagnosed
- 1.What is my exact diagnosis, stage, and grade, and which tests established them?
- 2.Which biomarkers have been tested on my tumour (for example RAS, BRAF V600E, MSI/dMMR, HER2, NTRK), and what were the results?
- 3.Which subtype is my cancer, and does that change the recommended treatment?
- 4.Is germline (inherited) genetic testing recommended for me or my family?
Screening
- 5.For my situation (screening), which of the standard options do you recommend and why?
- 6.Am I a candidate for Shield, and what side effects should I expect?
Stage II-III
- 7.For my situation (stage ii-iii), which of the standard options do you recommend and why?
- 8.Am I a candidate for Signatera, and what side effects should I expect?
- 9.How do the results of DYNAMIC apply to someone like me?
Metastatic, MSS
- 10.For my situation (metastatic, mss), which of the standard options do you recommend and why?
- 11.Am I a candidate for Encorafenib, Sotorasib, Adagrasib or related drugs, and what side effects should I expect?
Metastatic, dMMR
- 12.For my situation (metastatic, dmmr), which of the standard options do you recommend and why?
- 13.Am I a candidate for Pembrolizumab, Nivolumab, Dostarlimab, and what side effects should I expect?
Screening (average risk, age 45-75)
- 14.For my situation (screening (average risk, age 45-75)), which of the standard options do you recommend and why?
- 15.Am I a candidate for Shield, and what side effects should I expect?
Stage I-II colon
- 16.For my situation (stage i-ii colon), which of the standard options do you recommend and why?
- 17.Am I a candidate for CAPOX (capecitabine, oxaliplatin), and what side effects should I expect?
- 18.How do the results of DYNAMIC apply to someone like me?
Stage III colon, pMMR
- 19.For my situation (stage iii colon, pmmr), which of the standard options do you recommend and why?
- 20.Am I a candidate for FOLFOX (5-FU, leucovorin, oxaliplatin), CAPOX (capecitabine, oxaliplatin), and what side effects should I expect?
Stage III colon, dMMR
- 21.For my situation (stage iii colon, dmmr), which of the standard options do you recommend and why?
- 22.Am I a candidate for Atezolizumab, FOLFOX (5-FU, leucovorin, oxaliplatin), and what side effects should I expect?
- 23.How do the results of ATOMIC (Alliance A021502) and NICHE-2 apply to someone like me?
Locally advanced rectal, pMMR
- 24.For my situation (locally advanced rectal, pmmr), which of the standard options do you recommend and why?
- 25.Am I a candidate for FOLFOX (5-FU, leucovorin, oxaliplatin), and what side effects should I expect?
Locally advanced rectal, dMMR
- 26.For my situation (locally advanced rectal, dmmr), which of the standard options do you recommend and why?
- 27.Am I a candidate for Dostarlimab, and what side effects should I expect?
- 28.How do the results of AZUR-1 apply to someone like me?
Metastatic, dMMR/MSI-high, first line
- 29.For my situation (metastatic, dmmr/msi-high, first line), which of the standard options do you recommend and why?
- 30.Am I a candidate for Pembrolizumab, Nivolumab, Ipilimumab, and what side effects should I expect?
- 31.How do the results of KEYNOTE-177 and CheckMate 8HW apply to someone like me?
Metastatic, RAS/BRAF wild-type, left-sided
- 32.For my situation (metastatic, ras/braf wild-type, left-sided), which of the standard options do you recommend and why?
- 33.Am I a candidate for Panitumumab, Cetuximab, FOLFOX (5-FU, leucovorin, oxaliplatin) or related drugs, and what side effects should I expect?
- 34.How do the results of PARADIGM and CRYSTAL & FIRE-3 apply to someone like me?
Metastatic, RAS-mutant or right-sided (non-G12C)
- 35.For my situation (metastatic, ras-mutant or right-sided (non-g12c)), which of the standard options do you recommend and why?
- 36.Am I a candidate for Bevacizumab, FOLFOX (5-FU, leucovorin, oxaliplatin), FOLFIRI (5-FU, leucovorin, irinotecan) or related drugs, and what side effects should I expect?
Metastatic, BRAF V600E
- 37.For my situation (metastatic, braf v600e), which of the standard options do you recommend and why?
- 38.Am I a candidate for Encorafenib, Cetuximab, FOLFOX (5-FU, leucovorin, oxaliplatin) or related drugs, and what side effects should I expect?
- 39.How do the results of BREAKWATER apply to someone like me?
Metastatic, KRAS G12C
- 40.For my situation (metastatic, kras g12c), which of the standard options do you recommend and why?
- 41.Am I a candidate for Sotorasib, Adagrasib, Panitumumab or related drugs, and what side effects should I expect?
- 42.How do the results of CodeBreaK 300 apply to someone like me?
Metastatic, HER2-amplified, RAS wild-type
- 43.For my situation (metastatic, her2-amplified, ras wild-type), which of the standard options do you recommend and why?
- 44.Am I a candidate for Tucatinib, Trastuzumab, Trastuzumab deruxtecan, and what side effects should I expect?
- 45.How do the results of MOUNTAINEER & MOUNTAINEER-03 and DESTINY-CRC02 apply to someone like me?
Metastatic, refractory (third line and beyond)
- 46.For my situation (metastatic, refractory (third line and beyond)), which of the standard options do you recommend and why?
- 47.Am I a candidate for Trifluridine/tipiracil, Fruquintinib, Regorafenib or related drugs, and what side effects should I expect?
- 48.How do the results of SUNLIGHT and FRESCO-2 apply to someone like me?
Oligometastatic liver or lung disease
- 49.For my situation (oligometastatic liver or lung disease), which of the standard options do you recommend and why?
Any stage
- 50.Are there clinical trials I could join, for example of Daraxonrasib, Autogene cevumeran, Signatera, PF-08634404?
- 51.Would a second opinion at a high-volume centre change anything, and can you help arrange it?
- 52.What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?
- 53.I read that “MSS metastatic disease is immunotherapy-resistant”. How does that affect my plan?
- 54.I read that “Early-onset CRC causes unknown”. How does that affect my plan?
The words I may hear
- Faecal immunochemical test (FIT): A stool test for hidden blood, done at home every year.
- Total neoadjuvant therapy (TNT, rectal cancer): Giving all the chemotherapy and radiotherapy for rectal cancer before surgery rather than splitting it around the operation.
- Sidedness (left vs right colon): Where in the colon a tumour starts changes its biology and which drugs work.
- Abdominoperineal resection: Removing the rectum and anus together, leaving a permanent colostomy.
- Colonoscopy: Examining the whole large bowel with a flexible camera; polyps found on the way are removed (polypectomy), which prevents most bowel cancers.
- Consensus molecular subtypes (CMS1-4): The consensus molecular subtypes are four gene-expression groups of bowel cancer: immune (CMS1), canonical (CMS2), metabolic (CMS3), and mesenchymal (CMS4), with different prognoses.
- Total mesorectal excision (TME): The standard rectal cancer operation: the rectum is removed together with its surrounding fatty envelope (the mesorectum) in one intact package, which is where local recurrences used to come from.
- Glycaemic index and glycaemic load: How fast a food raises blood sugar (index) and how much, given the portion (load).
- Microsatellite-stable (MSS) / mismatch-repair proficient (pMMR): The 'normal' result on the mismatch-repair test: the tumour has intact DNA spell-checking and few mutations.
- Colectomy: Removing the part of the colon containing the cancer along with its blood supply and lymph nodes, then joining the ends.
Tests and results to bring
Biomarker results to ask for: RAS (KRAS/NRAS), BRAF V600E, MSI/dMMR, HER2, NTRK, sidedness, ctDNA MRD, RAS (KRAS and NRAS exons 2-4) for anti-EGFR eligibility, MMR/MSI status (universal testing at diagnosis), HER2 amplification (IHC/ISH or NGS), Primary tumour sidedness, NTRK fusions (rare), POLE/POLD1 (ultramutated, IO-responsive), ctDNA MRD after surgery (Signatera, Guardant Reveal), CEA (monitoring), UGT1A1*28 (irinotecan dosing) and DPYD (fluoropyrimidine toxicity), Germline testing for Lynch when dMMR or young onset.
Scans and tests linked to this cancer: CEA surveillance after colorectal cancer surgery, Colorectal cancer screening (colonoscopy, FIT, stool DNA, blood), Companion diagnostics, Comprehensive genomic profiling, DPYD genotyping and DPD phenotyping before fluoropyrimidines, Endoscopic ultrasound and EBUS systems.
Bring copies of scan reports, pathology and blood results, and a list of every medicine and supplement.
The treatments I may be offered
- Screening: Colonoscopy, FIT, Cologuard, Shield blood test from age 45. (Shield)
- Screening (average risk, age 45-75): Colonoscopy every 10 years, annual FIT, multitarget stool DNA every 3 years, CT colonography, or the Shield blood test every 3 years; start at 45 (USPSTF 2021). Lynch carriers: colonoscopy every 1-2 years from age 20-25. (Colorectal cancer screening (colonoscopy, FIT, stool DNA, blood), Shield, Faecal immunochemical test (FIT), Lynch syndrome)
- Stage II-III: Surgery; adjuvant chemotherapy guided by risk and (in trials) ctDNA; exercise programme. (DYNAMIC, Signatera, Exercise & lifestyle oncology)
- Stage I-II colon: Surgical resection; observation for stage I and low-risk stage II. High-risk stage II (T4, obstruction, <12 nodes, LVI): consider 3-6 months fluoropyrimidine ± oxaliplatin; ctDNA-negative patients can safely omit (DYNAMIC). dMMR stage II derives no benefit from 5-FU alone. (DYNAMIC, CAPOX (capecitabine, oxaliplatin), MRD / molecular residual disease testing)
- Stage III colon, pMMR: Resection then adjuvant CAPOX for 3 months (T1-3 N1, low risk) or FOLFOX/CAPOX for 6 months (T4 or N2), per IDEA. (FOLFOX (5-FU, leucovorin, oxaliplatin), CAPOX (capecitabine, oxaliplatin))
- Stage III colon, dMMR: Resection then FOLFOX + atezolizumab for 12 months (ATOMIC, 3-year DFS 86% vs 77%). Neoadjuvant nivolumab + ipilimumab (NICHE-2) is an alternative under evaluation. (ATOMIC (Alliance A021502), NICHE-2, Atezolizumab, FOLFOX (5-FU, leucovorin, oxaliplatin))
- Locally advanced rectal, pMMR: Total neoadjuvant therapy: short-course radiation or long-course chemoradiation plus FOLFOX/CAPOX, then TME surgery or watch-and-wait for clinical complete response (OPRA). Non-operative management for select cCR. (IMRT / IGRT (modern external beam), FOLFOX (5-FU, leucovorin, oxaliplatin), Clinical complete response (cCR))
- Locally advanced rectal, dMMR: Dostarlimab monotherapy for 6 months with organ preservation (MSK cohort 100% cCR; AZUR-1 registrational, PDUFA February 2027). Chemoradiation and surgery reserved for non-responders. (AZUR-1, Dostarlimab, Clinical complete response (cCR))
- Metastatic, MSS: Doublet/triplet chemotherapy + biologic by genotype; targeted combinations for BRAF, KRAS G12C, HER2. (Encorafenib, Sotorasib, Adagrasib, Tucatinib)
- Metastatic, dMMR: Checkpoint inhibitors; organ preservation in rectal cancer. (Pembrolizumab, Nivolumab, Dostarlimab)
- Metastatic, dMMR/MSI-high, first line: Pembrolizumab (KEYNOTE-177) or nivolumab + ipilimumab (CheckMate 8HW, PFS 54 months); nivolumab monotherapy alternative. Chemotherapy reserved for IO-refractory disease. (KEYNOTE-177, CheckMate 8HW, Pembrolizumab, Nivolumab, Ipilimumab)
- Metastatic, RAS/BRAF wild-type, left-sided: FOLFOX or FOLFIRI + panitumumab or cetuximab (PARADIGM OS 37.9 months); bevacizumab if anti-EGFR contraindicated. Maintenance fluoropyrimidine ± biologic after induction. (PARADIGM, CRYSTAL & FIRE-3, Panitumumab, Cetuximab, FOLFOX (5-FU, leucovorin, oxaliplatin), FOLFIRI (5-FU, leucovorin, irinotecan), Anti-EGFR antibody + chemotherapy in left-sided RAS/BRAF wild-type mCRC)
- Metastatic, RAS-mutant or right-sided (non-G12C): FOLFOX, FOLFIRI, or FOLFOXIRI + bevacizumab; anti-EGFR contraindicated. KRAS G12D and other alleles: RAS(ON) inhibitors in trials. (Bevacizumab, FOLFOX (5-FU, leucovorin, oxaliplatin), FOLFIRI (5-FU, leucovorin, irinotecan), Daraxonrasib)
- Metastatic, BRAF V600E: First line: encorafenib + cetuximab + mFOLFOX6 or FOLFIRI (BREAKWATER, OS 30.3 vs 15.1 months). Later line: encorafenib + cetuximab (BEACON). (BREAKWATER, Encorafenib, Cetuximab, FOLFOX (5-FU, leucovorin, oxaliplatin), FOLFIRI (5-FU, leucovorin, irinotecan))
- Metastatic, KRAS G12C: Sotorasib + panitumumab (CodeBreaK 300) or adagrasib + cetuximab after chemotherapy; first-line trials ongoing. (CodeBreaK 300, Sotorasib, Adagrasib, Panitumumab, Cetuximab, KRAS G12C inhibitor + anti-EGFR antibody (colorectal))
- Metastatic, HER2-amplified, RAS wild-type: Tucatinib + trastuzumab (MOUNTAINEER) or trastuzumab deruxtecan 5.4 mg/kg (DESTINY-CRC02) after chemotherapy; MOUNTAINEER-03 tests first-line use. (MOUNTAINEER & MOUNTAINEER-03, DESTINY-CRC02, Tucatinib, Trastuzumab, Trastuzumab deruxtecan)
- Oligometastatic liver or lung disease: Resection, thermal ablation, or SBRT with curative intent after multidisciplinary review; perioperative chemotherapy; 5-year survival 30-50% after complete resection of liver metastases. (Thermal ablation (RFA, microwave, cryo), SBRT / SABR (stereotactic radiotherapy), Robotic & minimally invasive surgery)
- Metastatic, refractory (third line and beyond): Trifluridine/tipiracil + bevacizumab (SUNLIGHT, OS 10.8 months), then fruquintinib (FRESCO-2) or regorafenib; NTRK inhibitor if fusion; clinical trials. (SUNLIGHT, FRESCO-2, Trifluridine/tipiracil, Fruquintinib, Regorafenib, Bevacizumab)
From the standard of care recorded for this cancer; which apply depends on your stage and biomarkers. Ask which the team recommends and why.
Answers and next steps
Saved in this browserWhat I was told
Agreed next steps, dates and who to call