Optimizing third-line and beyond therapies for metastatic colorectal cancer in Taiwan: an evidence-based consensus

Metastatic colorectal cancer (mCRC) is a major public health burden in Taiwan. Despite multiple later-line therapies, outcomes remain suboptimal. International guidelines provide valuable direction, but are difficult to apply locally due to differences in drug accessibility, reimbursement policies, and practice patterns.

This initiative developed a Taiwan-specific, consensus framework for managing mCRC in the third line and beyond.

This consensus integrated global evidence with local practice, real-world data, and reimbursement considerations.

A multidisciplinary panel of 20 experts convened by the Taiwan Society of Colon and Rectal Surgeons (TSCRS) used a modified Delphi process. Initial recommendations were adapted from European Society for Medical Oncology (ESMO), Pan-Asian ESMO, and National Comprehensive Cancer Network (NCCN) guidelines, supplemented by Taiwan real-world data. Consensus was achieved through three structured rounds of voting and discussion, with final statements graded by level of evidence and strength of agreement.

Twelve recommendations spanning three domains were endorsed: disease management, third-line options, and extended strategies. Key local adaptations include aligning imaging schedule intervals with Taiwan's National Health Insurance reimbursement policies and prioritizing trifluridine/tipiracil and regorafenib as preferred third-line agents. The panel acknowledged emerging options such as fruquintinib, epidermal growth factor receptor antibody rechallenge, and novel chemotherapy combinations. While the panel strongly supported biomarker-informed treatments, their broader implementation is constrained by limited reimbursement coverage for next-generation sequencing. Other challenges included limited drug access, suboptimal uptake of biomarker testing, and reimbursement constraints.

This Taiwan-specific consensus provides a practical, evidence-based framework for late-line mCRC treatment, bridging global standards with local realities to improve policy alignment and optimize patient outcomes.