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onc.colorectal-cancer.core.v1PRODUCTION
onc.colorectal-cancer.core.v1

Colorectal cancer (core)

oncologychronicadultgeriatric
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Determine scope: screening vs polyp vs newly-confirmed CRC vs metastatic; colon vs rectum (rectal triggers MRI + TNT pathway) (NCCN Colon/Rectal 2026)

Inputs
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Advance rule
Set
Advance when

Scope identified with anatomic site (colon vs rectum) (NCCN Colon/Rectal 2026)

Patient inputs (15)

MMR-IHC + MSI-PCR; MSI-H drives ICI first-line eligibility and Lynch screening

Hereditary syndrome risk drives germline testing and earlier screening cadence (NCCN germline 2024)

Performance status drives FOLFOXIRI fitness, surgical candidacy, palliative-vs-curative intent

BSA for cytotoxic dosing (Mosteller)

BSA computation

Screening eligibility (USPSTF 2021), surgical candidacy, IDEA adjuvant duration banding

Diagnostic gold standard; lesion biopsy + tattoo + synchronous-polyp survey

Staging — visceral/nodal metastases; AJCC stage assignment

Baseline CEA for post-treatment surveillance trending (NCCN Colon 2026)

Baseline cytopenias affect chemo dose intensity

Hepatic function for chemo dosing + irinotecan UGT1A1 considerations

Renal function for oxaliplatin/capecitabine dosing + contrast staging

Molecular panel drives first-line anti-EGFR vs anti-VEGF, BEACON triplet, MOUNTAINEER, and TRK inhibitor eligibility

KRAS WT left-sided primary derives greater benefit from anti-EGFR vs anti-VEGF first-line (CALGB/SWOG 80405)

Rectal cancer only — CRM, mesorectal nodes, T-staging for TNT vs surgical-first decision

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateninglarge_bowel_obstruction_or_perforation
    Obstructing or perforating CRC — closed-loop large-bowel obstruction, free air on imaging, faecal peritonitis
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninglower_gi_massive_hemorrhage
    Massive lower-GI bleed from CRC with hemodynamic instability or transfusion >4u
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningbevacizumab_gastrointestinal_perforation
    Acute abdomen + free air on imaging in a patient on bevacizumab — GI perforation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereoxaliplatin_grade_3_neuropathy
    Persistent grade 3 peripheral neuropathy interfering with ADLs
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_irae_on_ici_msi_h
    Grade >=3 irAE on ICI (especially dual nivo+ipi) — colitis, hepatitis, pneumonitis, myocarditis, severe endocrinopathy
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

CONTEXTrequiredDrives dose adjustment
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Recommended regimen

Adjuvant stage III colon — IDEA-driven FOLFOX/CAPOX duration
axis: crc_adjuvant_stage_iii_idea
Selected axis "Adjuvant stage III colon — IDEA-driven FOLFOX/CAPOX duration" by default fallback (first axis)
  • fluorouracil
    first line
    fluoropyrimidine
    400 mg/m2 bolus + 2400 mg/m2 over 46h • IV • q2w x 12 cycles (FOLFOX-6)
    triggers: adjuvant_stage_iii_t4_or_n2_high_risk
    MOSAIC + IDEA — FOLFOX backbone for high-risk stage III (T4 or N2) x 6 months
    rxcui 4492
  • leucovorin
    first line
    folinate
    400 mg/m2 • IV • q2w with 5-FU
    triggers: adjuvant_5fu_modulator
    5-FU modulator in FOLFOX
    rxcui 6313
  • oxaliplatin
    first line
    platinum_alkylating
    85 mg/m2 • IV • q2w x 12 cycles
    triggers: adjuvant_high_risk_t4_or_n2
    Oxaliplatin partner for high-risk stage III; cumulative neurotoxicity monitor
    rxcui 32592
  • capecitabine
    first line
    fluoropyrimidine
    1000 mg/m2 • PO • BID days 1-14 q3w x 4 cycles (CAPOX 3 months)
    triggers: adjuvant_stage_iii_low_risk_t1_3_n1
    IDEA (Grothey NEJM 2018 PMID 29590544) — CAPOX 3 months non-inferior to 6 months in low-risk stage III
    rxcui 194000

Auto-drafted A&P note

Subjective

- Possible entry pathways: Positive FIT or stool-DNA test on screening (USPSTF 2021); Polyp/mass identified at colonoscopy requiring biopsy or referral (USMSTF 2020); Rectal bleeding, occult-blood-positive anemia, or change in bowel habit (NCCN Colon/Rectal 2026).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Colorectal cancer (core)** (onc.colorectal-cancer.core.v1).
Phenotype framing: Adenocarcinoma (vast majority) vs neuroendocrine vs lymphoma vs metastasis to bowel; hereditary (Lynch/FAP/MUTYH/PJS) vs sporadic; field cancerization in IBD-associated dysplasia (NCCN Colon/Rectal 2026)
Scope: Determine scope: screening vs polyp vs newly-confirmed CRC vs metastatic; colon vs rectum (rectal triggers MRI + TNT pathway) (NCCN Colon/Rectal 2026)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Adjuvant stage III colon — IDEA-driven FOLFOX/CAPOX duration**.
1. fluorouracil 400 mg/m2 bolus + 2400 mg/m2 over 46h IV q2w x 12 cycles (FOLFOX-6) (fluoropyrimidine, first line) — MOSAIC + IDEA — FOLFOX backbone for high-risk stage III (T4 or N2) x 6 months
2. leucovorin 400 mg/m2 IV q2w with 5-FU (folinate, first line) — 5-FU modulator in FOLFOX
3. oxaliplatin 85 mg/m2 IV q2w x 12 cycles (platinum_alkylating, first line) — Oxaliplatin partner for high-risk stage III; cumulative neurotoxicity monitor
4. capecitabine 1000 mg/m2 PO BID days 1-14 q3w x 4 cycles (CAPOX 3 months) (fluoropyrimidine, first line) — IDEA (Grothey NEJM 2018 PMID 29590544) — CAPOX 3 months non-inferior to 6 months in low-risk stage III

AVOID / contraindication checks:
- Oxaliplatin_hold_grade_2_3_neuropathy
- Capecitabine_dose_reduce_creatinine_clearance_below_50
- 5fu_DPD_deficiency_screen_before_starting (fluorouracil)
- Capecitabine_hand_foot_syndrome_dose_hold_grade_3

Monitoring

Regimen monitoring:
- CBC LFT pre each cycle
- oxaliplatin neuropathy grading each visit
- CEA baseline then q3 6mo
- surveillance colonoscopy at 1 year post resection

Follow-up plan: NCCN survivorship intervals; Lynch cascade-testing for family if MMR-deficient; high-risk syndrome surveillance (annual EGD/colonoscopy for FAP, gynae screening for Lynch); long-term oxaliplatin neuropathy management; bowel-habit + ostomy care (NCCN Colon/Rectal 2026)
- Close-out criterion: Survivorship + cascade-testing + syndrome-surveillance plan documented (NCCN Colon/Rectal 2026)

Monitoring phase: CEA q3-6 mo x 5 yr post-curative; CT chest/abdomen/pelvis q6-12 mo x 3 yr for high-risk resected; surveillance colonoscopy at 1 yr then per polyp/USMSTF 2020 intervals; oxaliplatin neuropathy monitoring; on-ICI irAE TSH/LFT/glucose q2-4 wk (NCCN Colon/Rectal 2026)

Disposition

Disposition phase: Outpatient infusion suite for systemic therapy; inpatient for surgery (laparoscopic/robotic colectomy or TME for rectal), bowel obstruction relief, neutropenic fever, severe irAE, palliative escalation (NCCN Colon/Rectal 2026)
- Advance when: Care setting + treatment timeline established (NCCN Colon/Rectal 2026)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Obstructing or perforating CRC — closed-loop large-bowel obstruction, free air on imaging, faecal peritonitis
- [LIFE_THREATENING] Massive lower-GI bleed from CRC with hemodynamic instability or transfusion >4u
- [LIFE_THREATENING] Acute abdomen + free air on imaging in a patient on bevacizumab — GI perforation

Citations

- NCCN Colon 2026 + NCCN Rectal 2026 + USPSTF 2021 CRC screening + ASCO 2022 metastatic [PMID:29590544](https://pubmed.ncbi.nlm.nih.gov/29590544/)
- Cited evidence (PMID 31566309) [PMID:31566309](https://pubmed.ncbi.nlm.nih.gov/31566309/)
- Cited evidence (PMID 33264544) [PMID:33264544](https://pubmed.ncbi.nlm.nih.gov/33264544/)
- Cited evidence (PMID 34637336) [PMID:34637336](https://pubmed.ncbi.nlm.nih.gov/34637336/)
- Cited evidence (PMID 39602630) [PMID:39602630](https://pubmed.ncbi.nlm.nih.gov/39602630/)

Last reconciled with current guidelines: 2026-05-26.
References