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

Background: 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. Objectives: This initiative developed a Taiwan-specific, consensus framework for managing mCRC in the third line and beyond. Design: This consensus integrated global evidence with local practice, real-world data, and reimbursement considerations. Methods: 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. Results: 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. Conclusion: 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.