Delphi Initiative for Early-Onset Colorectal Cancer (DIRECt) International Management Guidelines.

Area of Science:

• Oncology
• Genetics
• Gastroenterology

Background:

• Current guidelines for colorectal cancer (CRC) lack age-specific recommendations for early-onset CRC (eoCRC).
• A multidisciplinary international expert group (DIRECt) developed the first evidence-based consensus recommendations for eoCRC management.
• The DIRECt group comprised 69 experts in the field.

Framework:

• A Delphi methodology was employed to address clinically relevant questions after a thorough literature review.
• Each statement required a ≥80% consensus level, achieved through 3 rounds of voting.
• The consensus covered 7 key areas: diagnosis, risk factors, genetics, pathology-oncology, endoscopy, therapy, and supportive care.

Implementation:

• Strong consensus supports risk stratification and prompt symptom assessment for individuals under 50.
• Germline genetic testing is recommended for all newly diagnosed eoCRC patients, preferably pre-surgery.
• Treatment approaches for eoCRC should align with later-onset CRC, except for patients with pathogenic germline variants.

Implications:

• The consensus highlights the need for fertility preservation and sexual health discussions for eoCRC survivors.
• Identified knowledge gaps include optimal screening age, use of fecal immunochemical tests, chemotherapy efficacy, endoscopic therapy, and surveillance strategies for eoCRC.
• These recommendations serve as a valuable clinical tool for managing eoCRC patients and guide future research priorities.