eBulletin Newsletter

NCCN Flash Updates: NCCN Guidelines and NCCN Templates Updated

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®), and the NCCN Drugs and Biologics Compendium (NCCN Compendium^®) for Breast Cancer. These NCCN Guidelines^® are currently available as Version 7.2021.

Link directly to the Updates section of the NCCN Guidelines:
NCCN Guidelines for Breast Cancer

Updates in Version 6.2021

• Preoperative/Adjuvant Therapy Regimens for HER2-Negative Disease (BINV-L, 1 of 8)
  • Option and footnote added for high risk triple-negative breast cancer (TNBC):
    • Preoperative pembrolizumab + carboplatin + paclitaxel, followed by preoperative pembrolizumab + cyclophosphamide + doxorubicin or epirubicin, followed by adjuvant pembrolizumab.
    • Footnote j: High-risk criteria include stage II-III TNBC. The use of adjuvant pembrolizumab (category 2A) may be individualized.
    • Reference: Schmid P, Cortes J, Pusztai L, et al. Pembrolizumab for early triple-negative breast cancer. N Engl J Med, 2020;382(9):810-821.on clinical and pathological stage (CPS) and estrogen-receptor status and histologic grade (EG).
  • Option modified: Olaparib if high risk and germline BRCA1/2 mutations
    • Footnote g modified: Consider addition of adjuvant olaparib for 1 y after adjuvant chemotherapy for those with germline BRCA1/2 mutations and either 1) TNBC and ≥pT2 or ≥ pN1 disease (category 1); or 2) HR-positive, HER2-negative ≥4 positive lymph nodes. For those with germline BRCA1/2 mutations and HR-positive, HER2-negative disease who received preoperative chemotherapy, consider adjuvant olaparib for 1 y if residual disease and a clinical stage, pathologic stage, estrogen receptor status, and tumor grade (CPS+EG) score ≥3. Adjuvant olaparib can be used concurrently with endocrine therapy.
    • Footnote removed: High-risk group includes those with no pCR and CPS+EG score of ≥3. The CPS+EG scoring system estimates probability of relapse based on clinical and pathological stage (CPS) and estrogen-receptor status and histologic grade (EG).

Updates in Version 7.2021

• Preoperative/Adjuvant Therapy Regimens for HER2-Negative Disease (BINV-L, 1 of 8) 
  • Correction to footnote g: Consider addition of adjuvant olaparib for 1 y for those with germline BRCA1/2 mutations and: 
    • TNBC, if 1) ≥pT2 or ≥ pN1 disease after adjuvant chemotherapy, or 2) residual disease after preoperative chemotherapy
    • HR-positive, HER2-negative tumors, if 1) ≥4 positive lymph nodes after adjuvant chemotherapy (category 2A), or 2) residual disease after preoperative therapy and a clinical stage, pathologic stage, estrogen receptor status, and tumor grade (CPS+EG) score ≥3 (category 2A).
      
      Adjuvant olaparib can be used concurrently with endocrine therapy.

Previous updates to the NCCN Guidelines for Breast Cancer can be found in the UPDATES section of the current version.



NCCN has published updates to the NCCN Guidelines and the NCCN Compendium^® for Hepatobiliary Cancers. These NCCN Guidelines are currently available as Version 4.2021.

Link directly to the Updates section of the NCCN Guidelines:
NCCN Guidelines for Hepatocellular Carcinoma

• Principles of Systemic Therapy HCC-G (1 of 2)
  • Subsequent-Line Therapy for Hepatocellular Carcinoma if Disease Progression:
    • Nivolumab (Child-Pugh Class B only) changed from category 2A to category 2B and moved from Other Recommended Regimens to Useful in Certain Circumstances. 
    • Other Recommended Regimens: Nivolumab was removed as a treatment option for patients with Child-Pugh Class A. 
  • Footnote k revised: Consider if MSI-H HCC.  Pembrolizumab is a recommended treatment option for patients with or without MSI-H HCC.
• The discussion section has been updated to reflect the changes in the algorithm (MS-1).

Previous updates to the NCCN Guidelines for Hepatobiliary Cancers can be found in the UPDATES section of the current version.

NCCN has published updates to the NCCN Guidelines for Adolescent and Young Adult Oncology. These NCCN Guidelines are currently available as Version 1.2022. 

Link directly to the Updates section of the NCCN Guidelines:
NCCN Guidelines for Adolescent and Young Adult Oncology

• Replaced the term infertility with impaired fertility throughout the guideline.
• Definition of the AYA Population and Purpose of the NCCN Guidelines for AYA Oncology (AYAO-1)
  • Deleted:
    • a patient population that saw little to no improvement in cancer survival for decades compared with younger and older patients.
    • Smith AW, Seibel NL, Lewis DR, et al. Next steps for adolescent and young adult oncology workshop: An update on progress and recommendations for the future. Cancer 2016;122:988-999. 
    • Closing the Gap: Research and Care Imperatives for Adolescents and Young Adults with Cancer Report of the Adolescent and Young Adult Oncology Progress Review  Group. 2006. https://www.cancer.gov/types/aya/research/ayao-august-2006.pdf 
  • Modified: The distinct biology of disease as well as other age-related issues in the AYA population (fertility, long-term side effects, insurance/financial issues, transportation to clinic appointments, child care, psychosocial support, and adherence to therapy) should be considered in the treatment decision-making process and during the transition of care from pediatric to adult medical teams.
• Comprehensive Initial Assessment (AYAO-3)
  • Modified:
    • All female patients of childbearing potential must receive a Consider a pregnancy test prior to initiating each cycle of therapy in accordance with institutional requirements.
    • Discuss risks of infertility impaired fertility due to cancer and its therapy, as well as fertility preservation options and consider referral to a fertility preservation/reproductive health program.
  • Zhang J, Walsh MF, Wu G, et al. Germline mutations in predisposition genes in pediatric cancer. N Engl J Med;2015;373:2236-2346.
• Treatment-Related Issues (AYAO-4)
  • Monitoring of cumulative dosing and schedule for Establish maximum cumulative dosing parameters and monitor cumulative dosing and schedule for certain medications associated with irreversible organ damage and fertility issues may be essential when certain lifetime exposure is encountered. See AYAO-10 for specific agents.
  • Maximum cumulative dosing parameters are often established for a patient to reduce the risk of significant irreversible damage. 
• Fertility and Reproductive Endocrine Considerations (AYAO-5 and AYAO-6)
  • These pages were extensively revised.
  • Added: NCCN recommendations have been developed to be inclusive of individuals of all sexual and gender identities to the greatest extent possible. On this page, the terms male and female refer to sex assigned at birth.
• Psychosocial/Behavioral Considerations: Individual (AYAO-7 and AYAO-8)
  • Evaluation, modified: Learning style/ Communication and information delivery.
  • Added: Evaluate for current and past psychiatric symptoms, including anxiety, depression, suicidal thoughts, and self injurious behavior.
  • Living status, added:
    • Friends/roommates
    • Homeless or nonstable living environment
  • New: Impact of cancer on support network:
    • Social isolation
    • Lack of will to discuss diagnosis due to feelings of shame or embarrassment
    • Loss of family or friends
    • Patient or family/caregiver involvement with criminal justice system or family court system
    • Patient or family/caregiver living in the United States without legal status/documentation 
    • Patient preference for information sharing and involvement of certain biological or chosen family members in care (and excluding others)
  • Supportive Care Services/Interventions, modified: Refer for neuropsychological assessment if there are concerns regarding the patient’s cognitive function (eg, attention, memory, executive function) and/or prior to educational and career transitions, including returning to school/work after treatment. Refer for neuropsycological cognitive assessment prior to educational and career transitions, including returning to school/work after treatment.
  • Modified: If child life specialists or appropriate psychosocial support are present on the unit, have them meet with the patient soon after diagnosis to address concerns that the patient has regarding treatment or procedures, as well as assist with coping mechanisms to reduce anxiety related to procedures.
  • Modified: Refer AYA patients with cognitive dysfunction or other psychiatric symptoms (eg, depression, anxiety) to a mental health provider and community-based resources serving AYA patients to screen for symptoms of depression, anxiety, suicidal ideation/behaviors, and self injurious behavior.
  • Changed LGBTQ to LGBTQIA2S+.
  • Added: Ensure record system accurately states patient's chosen pronouns.
  • Modified:
    • Adherence to therapy and safety plans. 
    • Simplify and modify dosing schedule and change timing and frequency of medication or method of administration, when medically possible, to fit into AYAs’ lifestyle and normal activities. 
    • Provide education on physical conditioning and related health benefits risks during and following cancer treatment. Refer to a rehabilitation specialist therapist (ie, physiatrist, physical therapist, occupational therapist) to address physical impairments and initiate physical activity interventions. Medical evaluation and a clearance by a physician (such as an oncologist or a physiatrist) are recommended prior to initiating exercise in patients in whom exercise modifications or precautions might be needed.
• Psychosocial/Behavioral Considerations: Relationships (AYAO-9 and 10)
  • Modified:
    • Gender identification and sexual orientation
    • Ongoing consideration for the level of information the AYA patient wishes to have and share regarding his/her disease and/or treatment.
    • Promote collaborative communication between AYA patients.
    • Early in the treatment process encourage education and the completion of a medical power of attorney and a living will at age of majority.
    • Provide identified family members and partners with information about psychosocial support and behavioral services.
    • Increase awareness and normalize of the possible psychosocial issues associated with cancer diagnosis in AYAs, so that family members and partners may continue to support the patient.
    • Provide AYA-specific activities and/or support groups, especially for inpatients to provide psychosocial support and reduce boredom, anxiety, and depression.
    • Ask for permission to share information with identified family members or supports.
  • Added:
    • If AYA patient is over 18 years of age, provide information on and necessary forms that legally allow medical information to be shared with caregivers of patient’s choice.
    • Always conduct medical and psychosocial care in the language preferred by the patient/family. Use certified interpreters and do not rely on family members, friends, or non-certified medical staff for interpretation.
• Psychosocial/Behavioral Considerations: Socioeconomic Issues (AYAO-11)
  • Evaluation, added: Assessment of financial toxicity.
  • Supportive care services/interventions, added:
    • Provide information regarding hospital pharmacy vouchers or low-cost medicine programs.
    • Provide school support and education services for patients in high school or college.
• Survivorship (AYAO-12)
  • Added: Always conduct medical and psychosocial care in the language preferred by the patient/family. Use certified interpreters and do not rely on family members, friends, or non-certified medical staff for interpretation. 
  • Modified: Counsel regarding striving to meet physical activity guidelines lifestyle practices and methods to reduce risk of long-term chronic health problems, recurrence, or new tumors (eg, avoiding smoking, increasing level of physical activity). 
• Survivorship: Table (AYAO-13)
  • Exposure and Recommendation:
    • Added: Total body irradiation (TBI): Thyroid disease screening, cardiovascular risk factor screening, and screening for secondary malignant neoplasms (SMNs)
    • Modified:
      • Cranial or craniospinal radiation: Ocular screening, audiological evaluation for doses ≥30 Gy, and colorectal cancer screening (for lumbar and sacral spine).
      • Neck radiation: Thyroid disease screening.
      • Cisplatin/carboplatin: Screening for gonadal function.
• Disease-Specific Issues Related to Age (AYAO-A)
  • Colorectal cancer modified: Lower incidence of KRAS mutations Greater mutation frequency of BRCA2, ATM, MSH2, and ATR. Tricoli JV, et al. Cancer 2018;124:1070-1082.
• Screening Recommendations for AYA Survivors (AYAO-B)
  • AYAO-B (1 of 4)
    • Gonadotropin deficiency, modified: Screening recommendation: follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone (individuals assigned male at birth), FSH, LH, and estradiol (individuals assigned female at birth) as clinically indicated. Referral for to reproductive endocrinologist recommended. 
    • Neuropsychological Evaluation:
      • Changed "neurocognitive" to "neuropsychological."
      • Added: Include information/education regarding neuropsychological evaluations, and/or cognitive screening for AYA survivors. Neuropsychological evaluations and/or cognitive screening may be warranted regardless of treatment history and should be offered if patient raises concerns.
  • AYAO-B (2 of 4)
    • Cardiovascular Risk Assessment and Screening:
      • Modified: High-risk population: ≥15 Gy combined with anthracycline or mediastinal/chest radiation ≥35 Gy alone, or abdominal radiation, or TBI mediastinal/chest radiation ≥20 Gy.
      • Added: Baseline ECG post treatment: not for treatment decision but definitely for when there is a subsequent issue for comparison.
    • Screening for Cardiomyopathy/Asymptomatic Heart Failure:
      • Modified: High-risk population: cumulative anthracycline dose ≥250 mg/m2, doxorubicin equivalent dose; chest radiation ≥35 Gy; combination of anthracycline and chest irradiation ≥15 Gy
      • Modified: Screening recommendation: echocardiogram every 2 years for high-risk patients and every 5 years for lower risk patients. 
    • Colorectal Cancer Screening added: or TBI.
    • Screening for Valvular Heart Disease modified: Screening recommendation: echocardiogram every 2 years for high-risk patients and every 5 years for lower risk patients
  • AYAO-B (3 of 4)
    • Assessment for Gonadal Function:
      • Changed males to Individuals assigned male at birth.
      • Changed females to Individuals assigned female at birth.
      • Modified: Infertility Impaired fertility: Temporary azoospermia or oligospermia can occur for variable periods of time post-therapy.
  • AYAO-B (4 of 4) 
    • Modified: Pregnancy in cancer survivors, modified: Referral of patients with cardiomyopathy, cardiovascular risk factors, and history of pelvic radiation to maternal-fetal medicine high-risk obstetrician with experience in treating pregnant cancer survivors.
  • Audiologic evaluation, added: Cancer survivors with hearing impairment should be provided with psychoeducational evaluation and support related to educational, psychological, and social function.
• Palliative Care Across the Disease Continuum and End-of-Life Considerations (AYAO-C)
  • Added: Consideration to include palliative care team or hospice services should be discussed early in treatment if prognosis is poor in order to provide the continuity of care and support for both patient and family throughout their cancer experience.
  • Added: Involve child life specialists and/or psychosocial team member to discuss legacy projects and memory work with patient and family.
  • Modified: Individual, family, and cultural differences influence the preferred location of death. While many adolescents indicate a preference for dying at home, 80% die in hospitals. Other AYAs and families choose to die in the hospital due to regional scarcities of home hospice, caregiver demand at the end of life, or personal preference. Every effort should be made to query and support AYA's preferred location of death. Physicians Clinicians with experience in end-of-life care should facilitate discussion about medical interventions such as nutrition/hydration, sedation, treatment cessation, and place of death.
  • Added: Clinical teams should be aware of and work with their palliative care teams regarding local guidelines for concurrent palliative and cancer-directed care
• Online Resources (AYAO-D, pages 1-5) – this section was deleted.

NCCN has published updates to the NCCN Chemotherapy Order Templates (NCCN Templates^®) for Breast Cancer to reflect the currently published NCCN Guidelines for Breast Cancer v7.2021.

• The following New NCCN Templates^® have been published:
  • BRS187a: Pembrolizumab + PACLitaxel/CARBOplatin followed by Pembrolizumab + Cyclophosphamide/[DOXOrubicin or EpiRUBicin] followed by Pembrolizumab - Pembrolizumab + PACLitaxel/CARBOplatin (Neoadjuvant Course 1)
  • BRS187b: Pembrolizumab + PACLitaxel/CARBOplatin followed by Pembrolizumab + Cyclophosphamide/[DOXOrubicin or EpiRUBicin] followed by Pembrolizumab - Pembrolizumab + Cyclophosphamide/[DOXOrubicin or EpiRUBicin](Neoadjuvant Course 2)
  • BRS187c: Pembrolizumab + PACLitaxel/CARBOplatin followed by Pembrolizumab + Cyclophosphamide/[DOXOrubicin or EpiRUBicin] followed by Pembrolizumab - Pembrolizumab (Adjuvant course)

For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Drugs & Biologics Compendium (NCCN Compendium^®), the NCCN Biomarkers Compendium^®, the NCCN Chemotherapy Order Templates (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/patientguidelines.

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

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