The National Comprehensive Cancer Network® (NCCN®)
held the NCCN 17th 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
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."
National Comprehensive Cancer Network