Consensus statement on the management of metastatic colorectal cancer beyond the second-line therapy in Saudi Arabia

BACKGROUND: The burden of metastatic colorectal cancer (mCRC) is considerable in Saudi Arabia, with an increased incidence rate and lower overall survival (OS) rate and characterized by earlier age of onset, more aggressive disease, and limited access to molecular diagnostics and advanced therapies in some regions. While international guidelines provide general management pathways, regional differences necessitate tailored recommendations for patients progressing beyond second-line treatment in Saudi Arabia. METHODS: A three-step modified Delphi method was adopted to develop the expert consensus on the management of mCRC beyond second-line therapy in Saudi Arabia. Ten medical oncologists from leading national cancer centers participated in the process, which included literature review, two voting rounds, and a panel discussion. RESULTS: The present consensus consisted of 56 statements reaching predefined agreement levels. The statements provided recommendations regarding the factors affecting treatment selection beyond second-line therapy, treatment sequencing in third and later lines of therapy, dosing modifications, management of toxicities, and the role of combination regimens in third and later lines. The consensus also underscores systemic disparities in drug access and the lack of real-world data or registries in Saudi Arabia. CONCLUSION: This consensus provides contextualized, evidence-based guidance to Saudi oncologists managing mCRC beyond second-line therapy. It emphasizes individualized treatment, toxicity control, and the need for national registries and biomarker research. The recommendations aim to improve consistency of care while acknowledging infrastructural and epidemiological challenges unique to the region.