Latest updates in clinical practice decision-making in cancer care presented at NCCN 17th conference

The National Comprehensive Cancer Network^® (NCCN^®) held the NCCN 17^th Annual Conference: Clinical Practice Guidelines & Quality Cancer Care^™, March 14 - 18 at The Westin Diplomat in Hollywood, Florida. The latest updates in clinical practice decision-making in cancer care were presented, including, but not limited to, the new NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®) for Lung Cancer Screening and updates to the NCCN Guidelines^® for Melanoma and Non-Hodgkin's Lymphomas.    

The NCCN Guidelines for Lung Cancer Screening, which were added to the Complete Library of NCCN Guidelines late last year, incorporate data from the National Lung Screening Trial (NLST). "In 2011, NCCN decided that the new data on lung cancer screening were important enough to address in separate guidelines," said Douglas E. Wood, MD, Professor and Chief of the Division of Cardiothoracic Surgery at the University of Washington/Seattle Cancer Care Alliance. "While we were working on our first guidelines, the results of the NLST became available, which makes this update very timely."

The NLST, the largest randomized lung screening study ever conducted, showed a substantial benefit for heavy smokers between the ages of 55-74 who had a series of helical computed tomography (CT) lung scans. CT screening identified more lung cancers at earlier stages and resulted in a significant decrease (20%) in lung cancer mortality in the screened group.

The NCCN Guidelines reflect these new findings and include algorithms for managing the different types of nodules that are detected in high-risk people who undergo helical low-dose CT scans. Distinguishing between malignant and non-malignant lesions is one of the challenges to screening high-risk smokers.

"Our goal is to recommend appropriate investigation for lesions that seem suspicious for lung cancer and to avoid interventions for those that are not. I think the NCCN algorithms provide good guidance to clinicians on managing different types of lung nodules," said Dr. Wood.

"These results are world changing," Dr. Wood said. "For the first time in my career, we can actually detect lung cancer at an earlier stage and decrease mortality from this disease. Lung cancer screening is the biggest news in a generation."

Significant additions to the NCCN Guidelines for Melanoma were also presented. Discussed were the addition of ipilimumab and vemurafenib as options for the treatment of advanced cases.

"We are really looking at the addition of two very exciting new agents in the treatment of systemic disease, one using immunotherapy (ipilimumab), the other using targeted therapy against a specific gene mutation (vemurafenib)," said Daniel G. Coit, MD, co-leader of the Melanoma Disease Management Team at Memorial Sloan-Kettering Cancer Center. "In addition, we are stressing the importance of screening patients with metastatic disease for the presence of the BRAF gene mutation to see if it can be a weapon in the treatment armamentarium." About half of patients with metastatic melanoma harbor an activating mutation of BRAF, a signaling kinase. These patients tend to show dramatic responses to vemurafenib.

Other updates presented include expanded recommendations on adjuvant therapy and radiation therapy. In addition, there is less emphasis on screening tests in Stage I and II melanoma. "We are working hard to define subgroups of patients at very low risk for distant disease or regional nodal disease who should not undergo extensive staging procedures," added Dr. Coit.

Attendees also learned about the latest NCCN Guidelines for Non-Hodgkin's Lymphomas (NHL), which include new guidelines for two lymphoid leukemia subtypes as well as modifications to the guidelines for immunophenotyping in the diagnosis of NHL.

"We have added clinical guidelines for both hairy cell leukemia and T-cell prolymphocytic leukemia to our NCCN Guidelines for NHL," said Andrew D. Zelenetz, MD, PhD, Department of Medicine Vice Chair of Medical Informatics at Memorial Sloan-Kettering Cancer Center. "These are rare diseases, but they do occur and there are effective treatments for both. The fact that they are so low in incidence makes the need for guidelines on appropriate management even more important."

The revised guidelines also include modifications to the recommendations for immunophenotyping and genetic testing that are used to help differentiate the subtypes of lymphoma. The guidelines emphasize the importance of integrating morphological findings, clinical features, and immunophenotyping studies for differential diagnosis.

"The panel wanted to improve the utility of these guidelines by making them easier to use. For example, the revised immunophenotyping guideline represents a more streamlined clinical decision-making tool that will be helpful both to pathologists and clinicians. Accurate diagnosis is essential in managing NHL." Dr. Zelenetz also noted that the NCCN Guidelines for NHL encompass 16 separate clinical entities classified as NHL. "This is a very complex set of diseases," he said. "They require complex recommendations for evaluation and treatment."