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NCCN Flash Update: NCCN Guidelines for Kidney & Prevention and Treatment of Cancer-Related Infections

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) and the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Kidney Cancer. These NCCN Guidelines® are currently available as Version 2.2018.

  • After primary treatment, the following was added under the heading "Adjuvant treatment" (KID-1)
    • For stage I, "surveillance"
    • For stage II, III
      • "Clear cell histology and high-risk: Clinical trial (preferred) or Surveillance or Adjuvant sunitinib (category 2B)" and "All others: Clinical trial or Surveillance."
  • Two corresponding footnotes were added
    • Footnote d, "High-risk defined as: tumor stage 3 or higher, regional lymph-node metastasis, or both."
    • Footnote e, "Dosing of adjuvant sunitinib: 50 mg per day - 4 weeks on, 2 weeks off for 1 year."

 

*For your reference, the previous update (Version 1.2018) to the NCCN Guidelines for Kidney Cancer, published on September 7, 2017, is available at the following link: https://www.nccn.org/professionals/physician_gls/pdf/kidney.pdf


The following NEW NCCN Chemotherapy Order Templates (NCCN Templates®) have been published to reflect the NCCN Guidelines for Kidney Cancer, Version 2.2018:

  • KDN28: SUNItinib

 

NCCN has published updates to the following NCCN Guidelines with NCCN Evidence Blocks™:

  • Soft Tissue Sarcoma, Version 1.2018

 

NCCN has published updates to the NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections. These NCCN Guidelines are currently available as Version 1.2018.

  • Prevention of Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV) Reactivation Or Disease (INF-5)
    • New pathway statement was added: "Consider screening all patients for HBV, HCV, and HIV prior to induction of immunosuppressive therapy (IST) or chemotherapy"
    • 1st statement under therapy considerations for HBV was revised: "ID Consult with an expert in hepatitis treatment to determine possible antiviral prophylaxis."
       
  • General Recommendations for Vaccination in Patients with Cancer (INF-7)
    • 1st bullet, "General comments" statement was revised: "Live viral vaccines should NOT be administered during chemotherapy or periods of significant immunosuppression, such as treatment of GVHD. The safety of vaccines in patients receiving immunostimulatory drugs has not been established." Also, a second sub-bullet was added: “All household members should be up-to-date with vaccines.”
    • 5th bullet, human papillomavirus (HPV) vaccination statement was revised: "The recombinant 3-dose HPV vaccine should be offered to patients of both sexes up to 26 years of age."
    • Footnote “mm” was added to title: “For prevention of infection in cancer survivors, including vaccination recommendations, see Survivorship Guidelines. “
       
  • Initial Empiric Therapy for Fever and Neutropenia (FEV-5)
    • "Levofloxacin" was added under: "Consider oral antibiotic therapy for select low-risk patients"
       
  • Additions to Initial Empiric Regimen (FEV-7)
    • For perirectal pain, a bullet: “Consider enterococcal coverage” and corresponding footnote: "Enterococcal colonization must be differentiated from infection. Vancomycin use must be minimized because of the risk of vancomycin resistance" were removed.
    •  For diarrhea, footnote "s" was revised: "The safety of probiotics or fecal microbiota transplantation (FMT) in this setting has not been shown. See Discussion section for adjunctive treatments for difficult C. difficile cases."
       
  • Additions to Initial Empiric Regimen for Lung Infiltrates (FEV-8)
    • 1st bullet was added by combining 2 other bullets: "Consider adding coverage for atypical bacteria (azithromycin, doxycycline, or fluoroquinolone)"
       
  • Follow-up Therapy for Responding Disease (FEV-11)
    • 1st bullet was added: "Targeted treatment of documented infections should be done"
    • 2nd bullet was added: "Reassessment of empiric Gram-negative therapy should be considered"
    • 3rd bullet was revised: "De-escalation and duration of antimicrobial therapy may be individualized…”
    • A bullet was removed: "Initial antibiotic regimen should generally be continued until neutrophil count is ≥500 cells/mcL and increasing"
       
  • Antibacterial Agents: Gram-Positive Activity (FEV-A) (1 of 4)
    • Footnote “c” about dosing adjustments was revised: "Requires dose adjustment in patients with renal insufficiency. Dosing variations exist based on age and other pharmacodynamic parameters."
      (Also for FEV-A 2 and 3 of 4)
  • Antibacterial Agents: Anti-Pseudomonal (FEV-A) (2 of 4)
    • Meropenem dose was revised: “1–2 g IV every 8 h (2 g IV every 8 h for meningitis)
    • Under “Comments/precautions” for cefepime and ceftazidime a bullet was removed: “Increased frequency of resistance among Gram-negative rod isolates at some centers"
    • Under “Comments/precautions” for piperacillin/tazobactam a bullet was removed: “May result in false-positive galactomannan.”
  • Antibacterial Agents: Other (FEV-A) (3 of 4)
    • Aminoglycosides dosing was revised: "Consider single loading dose in critically ill patients with individualized monitoring of levels. extended interval dosing."
    •  Trimethoprim/sulfamethoxazole (TMP/SMX) therapy
      • Therapy dose was clarified: “15 mg/kg daily in divided doses every 6–8 h based on the trimethoprim component"
      • 2nd bullet under “Comments/Cautions was revised: “"Monitor for renal insufficiency, myelosuppression, hepatotoxicity, and hyperkalemia"
         
  • Antifungal Agents: Azoles, Comments /Cautions  (FEV-B) (1 of 5)
    • 2nd bullet for isavuconazonium sulfate was added: "May shorten QTc interval"
       
  • Antifungal Agents: Azoles (FEV-B) (2 of 5)
    • 2nd bullet for posaconazole under “Comments/Cautions” was revised: "Liquid formulation has different dosing than tablet and should be administered with a full meal or liquid nutritional supplement or an acidic carbonated beverage. Tablet is better absorbed, though it should be taken with food."
    • Voriconazole therapy dose was revised for invasive aspergillosis and candidemia in non-neutropenic patients: “Loading dose: "6 mg/kg IV or 400 mg PO q12 x 2 doses on Day 1"
    • 6th bullet for voriconazole under “Comments /Cautions” was added: “Visual disturbances and hallucinations may occur on therapy”
       
  • Empiric Amphotericin B Formulations (FEV-B) (3 of 5)
    • Footnote "e" for liposomal amphotericin dosing was revised: "The vast majority of subjects in this trial had invasive aspergillosis; optimal dosing of L-AMB for other mold infections (such as mucormycosis with 3 5 mg/kg/d IV) was as effective but less toxic than 10 mg/kg/d as initial therapy for invasive mold infections."
       
  • Antifungal Agents: Echinocandins (FEV-B) (4 of 5)
    • This page has been extensively revised.
       
  • Antiviral Agents (FEV-C) (3 of 4)
    • "Tenofovir alafenamide (TAF) 25 mg PO daily" was added as a new formulation under "Common indication"
       
  • The Discussion section has been updated to reflect the changes in the algorithm. (MS-1)

 

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

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

Free NCCN Guidelines apps for iPhone, iPad, and Android smartphones & tablets are now available! Visit NCCN.org/apps

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