• H/P q 3 months X 3 years, then q 6 months years 4,5
• CEA q 3 monthly X 3 years, then q 6 months years 4,5 (CEA detects approx. 70% of metastatic recurrences)
• CT C/A/P annual X 3 years**
• Incomplete colonoscopy – scope within 6 months
• 1 year colonoscopy, if free of TA may go to 3 years, and if that is clear of TAs q5 yearly
• Consider d/c to family doctor after 1 year CT/scope
• Lifestyle: Encourage aerobic activity
• Stage 2 can consider discharging after 1 year (recommendation for annual CT Q 3 years….although there may be some exceptions to this ex: T4’s)

• H/P q 3 months X 3 years, then q 6 months years 4,5
• CEA q 3 monthly X 3 years, then q 6 months years 4,5
• CT C/A/P q 6 monthly X 3 years, then annual years 4,5
• Incomplete colonoscopy – scope within 6 months
• 1 year colonoscopy, if free of TA may go to 3 years, and if that is clear of TAs q5 yearly
• Consider d/c to family doctor after 2 years
• Lifestyle: Encourage aerobic activity
• Stage 3 we discussed following these patients for 2 years (highest risk time for recurrence), before discharging. Not sure if we came to a consensus on the imaging frequency.
• Circulating ctDNA testing made change this

Delay Ostomy reversal until post chemotherapy

**If high risk stage 2 (T4,PNI,LVI,obstructed at presentation, <11LN resected), optional to survey as stage III

Note that this is considerably more aggressive than BC Cancer MGMT guidelines which recommend “minimum of 2 scans over the first 3 years of f/u – months 12,36 suggested”

• TNT favoured for: cT4a/b, EMVI+, N2, MRF+, lateral LN+
  Generally RAPIDO style
• Short course RT and CAPOX X6 or FOLFOX X6
• Surgery 4 weeks post last cycle
  RT as early as possible
• Repeat rectal MRI and CT C/A/P post treatment
• Long course CRT
  GPO/MO assess q 2 weekly on treatment (order 2 weeks at a time)
• More frequent if having issues
• Labs weekly

• MDT will decide sequencing
• PET to exclude extrahepatic disease
• For resectable hepatic mets, generally we offer FOLFOX X4 to test biology and allow for HPB surgical planning
• May require further therapy for convertible disease, assess with PRIMIVIST MRI q 4 cycles
• Avoid irinotecan if possible
• CEA monitoring q cycle if elevated at baseline
• Ensure MMR and oncopanel requested
• Can consider FOLFIRINOX for BRAF mutated patients, or panitumumab/FOLFOX for pan RAS WT left sided tumours or bev/FOLFOX to boost response
• No bev within 4 weeks of surgery
• Resected Stage IV survey as per stage III above

• CEA monitoring q cycle if elevated at baseline
• Ensure MMR and oncopanel requested
• Prefer to add either bev or panitumumab if candidate with first line therapy
• Efficacy assessment with CT C/A/P at 3 months if marker is dropping, otherwise 2 months if marker rising or not elevated at baseline
• Thereafter, if responding CT C/A/P q 3 monthly and may increase interval to q 6 monthly for durable responders
• Resected Stage IV survey as per stage III above
• Urinalysis q cycle and ambulatory BP (home) if on bev
• BRAF mutated on TT (second line)
  • ECG at baseline, then Q monthly X 3
  • Derm at baseline, then q 8 weeks, then q 12 weekly