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Updated NCCN Practice Guidelines in Oncology Include 3 New Panels

May 2012, Vol 3, No 3

The National Comprehensive Cancer Network (NCCN) introduced 3 new panels to its Clinical Practice Guidelines in Oncology™ at its 2012 annual conference. The key components of these new guidelines are described below.

New Panel on Lung Cancer Screening

The new Lung Cancer Screening Panel recommended that persons at risk for lung cancer be screened regularly (in some cases, annually) with helical low-dose computed tomography (LDCT) in an effort to detect cancer at its earliest stage.

“If you leave this meeting with just one pearl of information, it should be that screening with low-dose chest CT [computed tomography] conclusively reduces mortality from lung cancer in high-risk patients,” said Douglas E. Wood, MD, of the University of Wash - ington/Seattle Cancer Care Alliance, who is the chair of the new panel.

The NCCN guidelines (1) describe the risk factors for lung cancer, (2) recommend criteria for selecting high-risk persons for screening, (3) provide recommendations for evaluation and follow-up of nodules found during screening, (4) discuss the accuracy of LDCT screening protocols and imaging modalities, and (5) discuss the benefits and risks of screening.

Ella Kazerooni, MD, of the University of Michigan Compre hensive Cancer Center, Ann Arbor, noted that the panel based the results on the landmark National Lung Screening Trial (Aberle DR, et al. N Engl J Med. 2011;365:395-409), which found that LDCT, compared with chest radiography alone, reduced lung cancer mortality by 20% and all-cause mortality by almost 7% among current or former smokers aged 55 to 75 years who underwent 3 annual LDCT scans.

However, lung cancer screening also resulted in a false-positive rate exceeding 90%. “Moving forward we need a good algorithm for managing the large number of false-positives we see,” Dr Kazerooni said.

Who Should Be Screened?

The NCCN guidelines recommend that individuals without symptoms of lung cancer be assessed for risk based on the following risk factors: smoking history, radon exposure, occupational exposure, cancer history, family history of lung cancer, lung disease history, and secondhand smoke exposure. Screening is recommended for high-risk patients who are:

  • Aged 55 to 74 years, with a ≥30-pack-year history of smoking tobacco; if a former smoker, must have quit within 15 years (category 1)
  • Aged ≥50 years and a ≥20-pack-year history of smoking and 1 additional risk factor (other than secondhand smoke; category 2B).

Further analyses of cost-effectiveness, resource utilization, quality of life, anxiety resulting from positive screens, and impact of smoking cessation are under way. These will be important in discussions regarding public health policy and reimbursement, Dr Kazerooni said.

Acute Lymphoblastic Leukemia Panel

New guidelines were also developed for acute lymphoblastic leukemia (ALL) and a new ALL panel estab lished. “On the pediatric side, there has been a significant advance in cure rates for ALL over the past decade, yet the story has not been near as rosy on the adult side,” said Patrick A. Brown, MD, the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore.

Half of all pediatric patients with ALL have 1 or 2 cytogenetic abnormalities that confer an excellent prognosis, approaching a curability rate of 100%, but these favorable abnormalities occur in <10% of adults with ALL. In contrast, BCL-ABL and T-cell lineage represent higher-risk subsets of ALL, and these are 3 times more common in adults. Also, the Philadelphia (Ph) chromosome, which is related to worse prognosis, is a common feature in adults with ALL but not in pediatric patients with ALL.

For this reason, molecular chromosomal analysis is key to the work-up of patients suspected of ALL. “For adults, the advancements in the next 5 to 10 years will come through better identification of molecular targets and novel therapeutic agents that can be added to dose-intensified therapy,” predicted Joseph C. Alvarnas, MD, of City of Hope Comprehensive Cancer Center, Duarte, CA.

An expert pathologist should also confirm the diagnosis through flow cytometry and chromosomal analysis to aid in stratifying patients by risk, which helps with treatment decision-making. “If patients have adverse risk factors or minimal residual disease, it is important to move to transplant earlier rather than later,” Dr Alvarnas said.

The NCCN Acute Lymphoblastic Leukemia Panel encourages the use of pediatric-inspired protocols for younger adults with ALL. The guidelines also recommend the incorporation of tyrosine kinase inhibitors for patients with Ph+ ALL, because these always improve outcomes.

The role of stem-cell transplantation remains unclear, although transplant is typically offered to suitable patients. Dr Brown emphasized the importance of an extended maintenance phase and the use of adequate central nervous system prophylaxis with intrathecal therapy to prevent relapse.

The panel recommends that patients with ALL be referred to specialized treatment centers if possible and enrolled in clinical trials.

Adolescents and Young Adults Oncology Panel

Also introduced were new supportive care guidelines that focus on the unique psychosocial issues of an underserved group—adolescents and young adults with cancer. “Compared with younger and older patients, there has been dismal progress in treating [adolescents and young adults] with cancer,” reported Peter F. Coccia, MD, of the University of Nebraska Eppley Cancer Center in Omaha. With no significant improvement in survival among patients aged 15 to 39 years, the need for addressing their unique needs has become clear and was the impetus for the new panel.

The reasons for poor outcomes in adolescents and young adults with cancer include low participation in clinical trials, unaddressed psychosocial issues, poor treatment adherence, and lack of a consistent treatment approach. Behavioral/psychosocial issues in adolescents and young adults center on interpersonal relationships, achievement disruption, emotional concerns, and existential/spiritual matters.

The NCCN’s Adolescent and Young Adult Oncology Panel’s goals for the guidelines are to:

  1. Identify issues applicable to the adolescent and young adult population and recommend interventions unique to this group
  2. Educate physicians about cancer in adolescents and young adults and its long-term consequences
  3. Identify considerations for managing cancer in adolescents and young adults
  4. Promote participation in clinical trials.

The guidelines for adolescents and young adults address age-appropriate care, fertility/endocrine considerations, psychosocial/behavioral issues, and survivorship, and they include online resources.

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