Metastatic colorectal cancers: guidelines from the first to the nth line in 2024

The management of patients with metastatic colorectal cancer (mCRC) is based on systemic chemotherapy and, when possible, resection or destruction of metastases. The FOLFOX protocol used perioperatively is the standard in cases of immediately resectable liver metastases. In other cases, the choice of the first-line chemotherapy protocol is based on other factors: the potential resectability of metastases in the event of an objective response, the patient's age, general condition and possible comorbidities, the molecular profile (RAS and BRAF gene status, dMMR/MSI phenotype), potential side effects of the protocols, the symptomatic or non-symptomatic nature of the disease, and tumor volume. Immunotherapy is indicated for the 4% of dMMR/MSI mCRC and chemotherapy (including between 1 and 3 cytotoxics) in combination with targeted therapy (anti-angiogenic if RAS or BRAF mutated and anti-EGFR if RAS/BRAF non-mutated) for the others. After the 1st line, 2nd, 3rd and 4th line treatments have demonstrated their efficacy and are available.