Fine-Tuning Cancer Care: NCCN Changes 11 Guidelines

John Eichorn
Published: Wednesday, Jun 01, 2011
The bond between
bevacizumab and vascular
endothelial growth factor

The bond between bevacizumab and vascular endothelial growth factor.

More than 1800 oncology specialists and other healthcare professionals turned out for the annual National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines & Quality Cancer Care conference, held in Hollywood, Florida, from March 9-13. Here are highlights on updates to the clinical practice guidelines:

New Options for Metastatic Breast Cancer

Eribulin (Halaven) has been added as a preferred single-agent option in the treatment of metastatic disease, while bevacizumab (Avastin), in combination with paclitaxel (Taxol), continues to be endorsed as treatment for patients with stage IV breast cancer. Denosumab (Xgeva) has been included in the guidelines as an additional option for the prevention of skeletal-related events.

A footnote was added discouraging axillary lymph node dissection in certain women with early breast cancer and a minimal number of positive lymph nodes. And, with available study results deemed inconsistent, testing for CYP2D6 polymorphisms in order to determine the efficacy of tamoxifen is not recommended at this time.

Timeline for CML Therapy Advanced

The second-generation tyrosine kinase inhibitors (TKIs) nilotinib (Tasigna) and dasatinib (Sprycel) are now recommended as first-line treatment for chronic myelogenous leukemia.

In monitoring response to therapy, complete cytogenic response remains the gold standard; however, not achieving complete molecular response should not be considered as treatment failure.

situ hybridization of labeled DNA

Photo shows in situ hybridization of labeled DNA, a known oncogene, that has been put into a mouse oocyte, where it paired with RNA (black dots in nucleus of immature cell).

HPV Testing for Head and Neck Cancer Endorsed

The guidelines now suggest that patients with oropharyngeal tumors be tested for the human papillomavirus (HPV). The guidelines also suggest that patients with hypopharyngeal cancer be evaluated and started on speech therapy as soon as possible to avoid severe speech impairment as the disease progresses.

However, the issue of induction theory remains contentious, so the guidelines have not changed in that regard. The ongoing DeCIDE trial is expected to determine whether induction therapy is beneficial.

Multiple Changes in Melanoma Strategy

Following the conference, the FDA approved ipilimumab (Yervoy) for the treatment of metastatic melanoma. On April 1, the NCCN added ipilimumab to the guidelines as a category 1 treatment option (ie, based on high-level evidence from randomized controlled trials) for patients with advanced or metastatic melanoma, although a footnote was added to warn of possible significant immunemediated complications.

Mitotic index, the single most important predictor of survival, now replaces Clark level in defining clinical stage IB melanoma.

The guidelines have been updated to note that routine imaging is no longer recommended for stage IIA melanoma patients with negative lymph nodes. Previous guidelines noted that this decision was left to the discretion of the clinician.

A footnote was added to the section regarding the use of interferon alfa in the adjuvant treatment of stage III disease, indicating that the drug can be given as high-dose interferon for 1 year or peginterferon alfa-b for 5 years.

Although there is no hard-and-fast rule about which patients should have one, physicians should discuss the possibility of sentinel lymph node biopsies with patients who have stage IB or stage II disease.

Multiple Myeloma Guidelines Adjusted

The serum-free light chain assay and the fluorescence in situ hybridization for 1q21 amplification are now a recommended part of the initial diagnostic workup.

The combination of bortezomib/cyclophosphamide/ dexamethasone has been added as primary induction therapy for transplant candidates. The bortezomib/dexamethasone combination and the melphalan/prednisone/lenalidomide combination have been included as therapy for primary induction for nontransplant candidates.

The combinations of cyclophosphamide/bortezomib/ dexamethasone and cyclophosphamide/lenalidomide/ dexamethasone are now recommended for salvage therapy. The combinations of bortezomib/ dexamethasone and cyclophosphamide/thalidomide/ dexamethasone have been added to the guidelines as initial treatment for amyloidosis.

View Conference Coverage
Online CME Activities
TitleExpiration DateCME Credits
Community Practice Connections™: 18th Annual International Lung Cancer Congress®Oct 31, 20181.5
Clinical Interchange™: Translating Research to Inform Changing Paradigms: Assessment of Emerging Immuno-Oncology Strategies and Combinations across Lung, Head and Neck, and Bladder CancersOct 31, 20182.0
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