NCCN Guidelines and Compendium Updated
Flash Update Sent January 25, 2012
NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Non-Hodgkin's Lymphomas. These NCCN Guidelines® are currently available as Version 1.2012.
- New guidelines were developed for the treatment of T-cell Prolymphocytic Leukemia and Hairy Cell Leukemia.
- Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
- "Bendamustine + rituximab" as a first-line and relapsed/refractory therapy for CLL with del(17p) was removed.
- "Chlorambucil ± rituximab" replaced "chlorambucil ± prednisone" for frail patients/patients with significant comorbidity and for patients ≥70 years of age (for both first-line and relapse/refractory therapy) with CLL without del(11q) or del(17p) or CLL with del(11q).
- Follicular lymphoma
- The category designation for first-line therapy with "bendamustine + rituximab" was changed from a category 1 to a category 2A recommendation.
- The category designation for first-line therapy with "RFND (rituximab, fludarabine, mitoxantrone, dexamethasone)" was changed from a category 2A to a category 2B recommendation.
- The category designation for first-line therapy with "radioimmunotherapy" was changed from a category 2B to a category 3 recommendation.
- "Fludarabine + rituximab" was removed as first-line therapy.
- Clarification was made to indicate that first-line consolidation or extended dosing was "optional".
- "BVR (bendamustine, bortezomib, rituximab)" and "fludarabine + rituximab" were added as second-line and subsequent therapy.
- Mantle cell lymphoma
- A new category for suggested treatment regimens, "for patients without intention for high dose therapy with stem cell rescue consolidation" was added with "if treated with RCHOP, consider rituximab maintenance 375 mg/m2 every 8 wks until progression".
- Diffuse large B-cell lymphoma (DLBCL)
- A new category for suggested treatment regimens, "Concurrent presentation with CNS disease" was added with "Parenchymal: 3 g/m2 or more of systemic methotrexate at count recovery as an alternating regimen" and "Leptomeningeal: IT methotrexate/cytarabine, consider Ommaya reservoir placement and/or systemic methotrexate (3-3.5 g/m2)".
- The category designation for first-line therapy "dose dense RCHOP 14" was changed from a category 2B to a category 3 recommendation.
- Clarification was made to indicate that first-line consolidation was "optional"; wording added for high-dose therapy with autologous stem cell rescue to include "patients with age-adjusted IPI high risk disease".
- "Bendamustine ± rituximab" was added as second-line therapy for patients who are non-candidates for high dose therapy.
- Burkitt lymphoma (BL)
- Induction therapy, the CALGB 9251 regimen was changed to the CALGB 10002 regimen with the addition of "+ rituximab".
- "RICE (rituximab, ifosfamide, carboplatin, etoposide); intrathecal methotrexate if have not received previously" was added as second-line therapy.
- Footnote was added to clarify that all regimens for Burkitt lymphoma include CNS prophylaxis/therapy.
- AIDS-related B-cell lymphoma
- Burkitt lymphoma: "HyperCVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with high-dose methotrexate and cytarabine) ± rituximab" was added as a treatment option.
- Burkitt lymphoma: "Consider CHOP with high-dose methotrexate ± rituximab" was removed as a treatment option.
- Peripheral T-cell lymphomas
- "CHOEP-21 (cyclophosphamide, doxorubicin, vincristine, etoposide and prednisone)" was added as first-line therapy for ALCL, ALK+ histology.
- A statement regarding the treatment of breast implant-associated ALCL was added.
- Extranodal NK/T-cell Lymphoma, nasal type
- "AspaMetDex (L-asparaginase, methotrexate, and dexamethasone) (Reported as a second line regimen.)" was added as a combination chemotherapy regimen.
- "SMILE (steroid [dexamethasone], methotrexate, ifosfamide, L-asparaginase, and etoposide) followed by RT 45-50.4 Gy" and "VIPD (etoposide, ifosfamide, cisplatin, and dexamethasone) followed by RT 45-50.4 Gy" were added as sequential chemoradiation regimens.
- The CLL/SLL, DLBCL, and BL sections of the Discussion have been updated to reflect the changes in the algorithms.
NCCN has published updates to the NCCN Guidelines and NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Waldenström's Macroglobulinemia. These NCCN Guidelines are currently available as Version 1.2012.
- A new footnote was added stating "Lymphoplasmacytic lymphoma (LPL) does encompass IgG, IgA, and non secretory subtypes though make up <5% of all LPLs. The treatment non-IgM LPLs parallels that of IgM secreting LPLs, but these are less likely to have either hyperviscosity associated with them, or autoimmune related neuropathy."
- New treatment regimens were added as options for both primary and salvage therapy with new and modified footnotes.
- The new treatment regimens included under primary and salvage therapy are: cyclophosphamide/doxorubicin/vincristine/prednisone/rituximab (category 2A); bortezomib/dexamethasone (category 2A); and fludarabine/cyclophosphamide/rituximab (category 2A).
- Ofatumumab (category 2A) is included as a salvage therapy option for rituximab intolerant individuals.
- A new page was added titled "Response Criteria for Waldenstrom's Macroglobulinemia/Lymphoplasmacytic Lymphoma".
- The Discussion section was updated to reflect changes made in the algorithms.
Flash Update Sent January 30, 2012
NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Breast Cancer. These NCCN Guidelines® are currently available as Version 1.2012.
- Invasive Breast Cancer
- Work-up of recurrent disease or initial work-up for Stage IV disease
- A footnote was added for clarification stating "False negative ER and/or PR determinations occur, and there may be discordance between the ER and/or PR determination between the primary and metastatic tumor(s). Therefore, endocrine therapy with its low attendant toxicity may be considered in patients with non-visceral or asymptomatic visceral tumors, especially in patients with clinical characteristics predicting for a hormone receptor positive tumor (eg, long disease free interval, limited sites of recurrence, indolent disease, or older age)." (page: BINV-16)
- Under systemic adjuvant therapy
- For patients with hormone receptor positive, HER2 negative disease ( pT1, pT2, or pT3 and pNmi (< 2 mm axillary node metastasis), with microinvasive or < 0.5 cm tumors, adjuvant chemotherapy along with endocrine therapy was added as a category 2B option (page: BINV-6). Previously endocrine therapy (category 2B) was the only option listed for these patients.
- The duration of adjuvant for endocrine therapy in both premenopausal and postmenopausal women was revised (page: BINV-J).
- Under systemic treatment of recurrent or stage IV disease
- In postmenopausal patients with hormone-positive disease, with no prior endocrine therapy within the past year, and with a plan to undergo aromatase inhibitor therapy (page: BINV-18), a new footnote was added stating "A single study (S0226) in women with hormone receptor-positive breast cancer and no prior chemotherapy, biological therapy, or endocrine therapy for metastatic disease demonstrated that the addition of fulvestrant to anastrozole resulted in prolongation of time to progression (Hazard rate for recurrence 0.80; 95% CI 0.68 - 0.94; stratified log-rank P = 0.007) and improvement in overall survival (Hazard rate 0.81; 95% CI 0.65- 1.00; stratified log-rank P = 0.049). Subset analysis suggested that patients without prior adjuvant tamoxifen and more than 10 years since diagnosis experienced the greatest benefit. A study of similar design (FACT) demonstrated no advantage in time to progression with the addition of fulvestrant to anastrozole (Hazard rate 0.99; 95% CI 0.81-1.20; P = 0.91)."
- Surgical axillary staging for I, IIA, IIB and lllA T3, N1, M0 (page: BINV- D) the following was added:
- For patients clinically node positive at time of diagnosis and found to be FNA or core biopsy positive, axillary dissection level l/ll.
- Principles of Monitoring Metastatic Disease is new to the Guidelines (page: BINV-M).
- On the page listing subsequent endocrine therapy for patients (page: BINV-N), a new footnote was added stating "A single study (BOLERO-2) in women with hormone receptor-positive, HER2-negative metastatic breast cancer and prior therapy with a nonsteroidal aromatase inhibitor demonstrated improvement in time to progression with the addition of everolimus (an mTOR inhibitor) to exemestane (Hazard rate 0.44; 95% CI 0.36-0.53; log-rank P = <1 x 10-16) and with increase in toxicity. No survival analysis is available. A randomized study using the mTOR inhibitor temsirolimus in combination with endocrine therapy did not demonstrate any improvement in outcome. Consider the addition of everolimus to exemestane in women who fulfill the eligibility criteria of BOLERO-2."
- Breast Cancer During Pregnancy
- The footnote 'c' was modified to include that the "use of paclitaxel weekly administration after the first trimester is acceptable if clinically indicated by disease status".
- Discussion section was updated to reflect the changes in the algorithm.
For the complete updated version of these and all NCCN Guidelines, visit NCCN.org.