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NCCN Flash Update: NCCN Guidelines Updated for Cervical & Uterine Cancers

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®), the NCCN Drugs and Biologics Compendium (NCCN Compendium®), and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™) for Cervical Cancer. These NCCN Guidelines® are currently available as Version 1.2018.

  • Global changes
    • The AJCC Cancer Staging tables (7th Edition) were updated to the 8th Edition for carcinoma of the cervix.
       
  • Workup (CERV-1)
    • The recommendation “Consider HIV testing” changed from category 3 to category 2A. Corresponding footnote “c” added: “Consider HIV testing, especially in younger patients. Patients with cervical cancer and HIV should be referred to an HIV specialist and should be treated for cervical cancer as per these guidelines. Modifications to cancer treatment should not be made solely on the basis of HIV status.”
       
  • Primary Treatment (Non-Fertility Sparing) (CERV-3)
    • For Stage IA1 no LVSI with positive margins for dysplasia or carcinoma after cone biopsy, recommendation revised: “Consider repeat cone biopsy to better evaluate depth of invasion to rule out Stage IA2/IB1 disease.”
       
  • Adjuvant Treatment
    • For patients with para-aortic lymph node positive by surgical staging, revised: “Consider Biopsy of suspicious areas as indicated.” (CERV-5) This change also made for patients positive for distant metastasis after radiologic workup. (CERV-8)
    • Footnote s is new: “Patients with high-risk pathologic features meeting Sedlis criteria and/or positive nodes are no longer candidates for fertility sparing.” (CERV-5)
       
  • Incidental Finding of Invasive Cancer After Simple Hysterectomy (CERV-9)
    • Staging revised: “≥ Stage IA1 with LVSI” changed to: “Stage IA1 with LVSI or Stage IA2/IB or positive margins/gross residual disease.”
    • Treatment: For patients with negative nodes and no residual disease after Complete parametrectomy/upper vaginectomy + pelvic lymph node dissection± para-aortic lymph node sampling,” the following option was removed: “Optional pelvic EBRT ± vaginal brachytherapy if large primary tumor, deep stromal invasion and/or LVSI.”
       
  • Local/regional recurrence (CERV-11)
    • For patients with noncentral disease who had prior RT, after “Therapy for Relapse,” a new pathway was added for “Recurrence.”
       
  • Principles of Imaging (CERV-A)
    • A new section added for “Suspected Recurrence or Metastasis that includes “Consider whole body PET/CT.”
       
  • Principles of Radiation (CERV-C)
    • This section was extensively revised.
       
  • Systemic Therapy Regimens for Cervical Cancer (CERV-E)
    • Previously this section was titled “Chemotherapy Regimens for Recurrent or Metastatic Cervical Cancer”
    • A new section added for “Chemoradiation (preferred regimens)” that includes “Cisplatin” and “Cisplatin/fluorouracil.”
    • Recurrent or Metastatic Disease; Second-line Therapy: “Pembrolizumab (for MSH-H/dMMR tumors)” added as a category 2B recommendation.
    • Footnote regarding first-line combination therapy is new: “These agents can be used as second-line therapy if not used previously.”

 

 

NCCN has published updates to the NCCN Guidelines, the NCCN Compendium®, and the NCCN Imaging AUC™ for Uterine Neoplasms. These NCCN Guidelines are currently available as Version 1.2018.

  • Global changes
    • The AJCC Cancer Staging tables (7th Edition) were updated to the 8th Edition for uterine carcinomas and carcinosarcoma, as well as uterine sarcoma.
    • The Discussion has been updated to reflect the changes in the algorithm. (MS-1)
    • Principles of Radiation: This section was extensively revised. (UN-A)
       
  • Endometrial Carcinoma
    • Primary Treatment
      • For patients with disease limited to the uterus (endometrioid histology) and not suitable for primary surgery, revised: “EBRT and/or brachytherapy (preferred)” (ENDO-1)
      • For patients with suspected extrauterine disease (endometrioid histology) that is initially unresectable, revised: “EBRT and/or ± brachytherapy ± systemic therapy”. (ENDO-3)
         
    • Adjuvant Treatment
      • For Stage IA (<50% myometrial invasion) grade 3 tumors with adverse risk factors, “Observe” removed as an option and revised: “Vaginal brachytherapy and/or EBRT ± systemic therapy (category 2B).”  (ENDO-4)
      • For Stage IB (≥50% myometrial invasion) Grade 3 tumors with no adverse risk factors, “Observe” removed as an option and revised: “Vaginal brachytherapy and/or EBRT ± systemic therapy (category 2B)” (ENDO-4)
      • For Stage IB (≥50% myometrial invasion); Grade 3 tumors with adverse risk factors, revised: “EBRT and/or vaginal brachytherapy ± systemic therapy (category 2B for systemic therapy)” (ENDO-4)
      • Footnote “r” regarding Stage II disease revised: “The adverse fundal risk factors influencing therapy decisions for stage I disease such as depth of myometrial invasion and LVSI may also impact the choice of adjuvant therapy for stage II disease.” (ENDO-5)
    • High-Risk Carcinoma Histologies (ENDO-11)
      • Previously this section was called “Serous or Clear Cell Carcinoma or Carcinosarcoma of the Endometrium.”
      • “Undifferentiated/dedifferentiated carcinoma” added to the list of high-risk histologies.
      • Adjuvant Treatment
        • For Stage IA, the option “Chemotherapy ± vaginal brachytherapy” is now listed as preferred.
      • Footnote c added: “Minimally invasive surgery (MIS) is the preferred approach when technically feasible. See Principles of Evaluation and Surgical Staging (ENDO-C).”
    • Principles of Imaging (ENDO-A)
      • A new section for “Suspected Recurrence or Metastasis” was added.
    • Hysterectomy and Pathologic Evaluation (ENDO-B)
      • Under “Pathologic assessment to include”, revised:
        • Nodes: “Size of metastasis (isolated tumor cells, micrometastasis, macrometastasis)” added.
        • Added “Estrogen receptor (ER) testing in setting of stage III, IV, and recurrent disease”.
    • Principles of Evaluation and Surgical Staging (ENDO-C)
      • Seventh bullet revised: “Sentinel lymph node (SLN) mapping may be considered in select patients.”
    • Systemic Therapy for Recurrent, Metastatic, or High-Risk Disease (ENDO-D)
      • Chemotherapy Regimens
        • "Multi-agent chemotherapy regimens preferred, if tolerated":
          • "Everolimus/letrozole (for endometrioid histology)" added as an option.
        • Single agents
          • "Albumin-bound paclitaxel" added with corresponding footnote: "Albumin-bound paclitaxel is a reasonable substitute for patients with a hypersensitivity to paclitaxel if the skin testing to paclitaxel is negative. If the patient has a positive skin test to paclitaxel then the patient requires desensitization to paclitaxel. Albumin-bound paclitaxel is not a reasonable substitute for paclitaxel if the patient’s skin test is positive."
          • "Pembrolizumab (for MSI-H/dMMR tumors)" added with corresponding footnote: "For recurrent endometrial cancer, NCCN recommends MSI-H or dMMR testing if not previously done. Pembrolizumab is indicated for patients with MSI-H or dMMR tumors that have progressed following prior cytotoxic chemotherapy."
        • A new section for "Adjuvant Treatment for Uterine-Confined Disease" was added that includes "Carboplatin/paclitaxel (preferred)."
        • Hormone Therapy: "Fulvestrant" added as an option.
           
  • Uterine Sarcoma
    • Additional Evaluation: “ER/PR testing” added as a recommendation. (UTSARC-1)
    • Diagnosed after TH or supracervical hysterectomy (SCH) ± BSO: For patients with residual disease in the tube/ovary recommendation revised: "Consider reresection unilateral salpingo-oophorectomy (USO)/BSO especially if low-grade ESS or ER-positive tumor." (UTSARC-1)
    • Footnote c revised: "Oophorectomy individualized for reproductive-age patients. Favor BSO if ER/PR positive."
    • Low-grade ESS: Under “Additional Therapy” (UTSARC-2)
      • Hormone therapy changed to “Estrogen blockade” for all stages.
      • For stage I, revised: “Observe, especially if menopausal or prior BSO or Estrogen blockade (category 2B).”
    • Therapy for Relapse (UTSARC-5)
      • Patients who did not receive prior RT
        • Revised “Consider preoperative EBRT ± systemic therapy” 
        • The recommendations following “Surgical exploration + resection ± IORT... ” were extensively revised.
        • Footnote g regarding systemic therapy now includes the following: “For low-grade ESS, the first choice of systemic therapy is estrogen blockade.”
    • Systemic therapy (UTSARC-B)
      • This section was extensively revised including:
        • Reorganizing the page into the following headings: “Preferred Therapies, Other Combination Regimens, Other Single-Agent Options, Other Hormone Therapies.
        • Footnote 2 is new: “Pazopanib may be considered for use in patients with recurrent or metastatic disease who have progressed on prior cytotoxic chemotherapy.”

For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Compendium, the NCCN Biomarkers Compendium®, the NCCN Chemotherapy Order Templates (NCCN Templates®), the NCCN Radiation Therapy Compendium™, and the NCCN Imaging AUC™, please visit NCCN.org.

To view the NCCN Guidelines for Patients®, please visit NCCN.org/patients.

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