eBulletin Newsletter

NCCN Flash Updates: NCCN Guidelines and NCCN Template 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 Bladder Cancer. These NCCN Guidelines^® are currently available as Version 5.2021.

Link directly to the Updates section of the NCCN Guidelines: 
Bladder Cancer

BL-5 and BL-7

• For stage II and IIIA, adjuvant treatment revised: Based on pathologic risk
  • If no cisplatin neoadjuvant treatment given and pT3, pT4a, or pN+
    • Adjuvant cisplatin-based chemotherapy should be discussed (preferred) or
    • Consider adjuvant nivolumab
  • If cisplatin neoadjuvant chemotherapy given and ypT2-ypT4a or ypN+, consider nivolumab
  • Consider adjuvant RT in selected patients (T3–4, positive nodes/margins) (category 2B)
• Footnote added: Most appropriate for patients who value an opportunity to delay recurrence even if the chance of cure was not improved, and for whom the risk of side effects was acceptable.

BL-G (1 of 7)

• Neoadjuvant chemotherapy [preferred for bladder]
  • Preferred regimens:
    • Revised: DDMVAC (dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin) with growth factor support for 3 or 4 3-6 cycles
  • Gemcitabine and cisplatin for 4 cycles moved to Other recommended regimens
• Other Recommended regimens:
  • Removed: CMV (cisplatin, methotrexate, and vinblastine) for 3 cycles
• Adjuvant therapy recommendations with the addition of nivolumab moved to a new table.

BL-G (2 of 7)

• First-line systemic therapy for locally advanced or metastatic disease, cisplatin ineligible revised: Pembrolizumab (only for patients whose tumors express PD-L1 or who are not eligible for any platinum-containing chemotherapy regardless of PD-L1 expression for the treatment of patients with locally advanced or metastatic urothelial carcinoma who are not eligible for any platinum-containing chemotherapy)

UTT-3

• Adjuvant treatment revised:
  • If no platinum neoadjuvant treatment given and pT3, pT4, or pN+
    • Adjuvant platinum-based chemotherapy should be discussed or
    • Consider adjuvant nivolumab (category 2B) or
  • If platinum neoadjuvant chemotherapy given and ypT2-ypT4 or ypN+, consider adjuvant nivolumab
  • ± RT (T3, T4, or N+)
• Footnote added: Most appropriate for patients who value an opportunity to delay recurrence even if the chance of cure was not improved, and for whom the risk of side effects was acceptable.

Previous updates to the NCCN Guidelines for Bladder 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 Multiple Myeloma. These NCCN Guidelines are currently available as Version 2.2022.

Link directly to the Updates section of the NCCN Guidelines: 
Multiple Myeloma

Updates in version 2.2022

• Maintenance Therapy (MYEL-G 1 and 2 of 4)
  • Other Recommended Regimens
    • Ixazomib was modified to: Ixazomib (category 1 category 2B)
  • Footnote i added: Results from interim analyses of TOURMALINE MM3 and MM4 trials of ixazomib in the maintenance setting suggests a potential decrease in overall survival.
• Primary Therapy for Non-Transplant Candidates (MYEL-G 2 of 4)
  • Preferred Regimens
    • Footnote j removed from regimen Bortezomib/lenalidomide/dexamethasone: This is the only regimen shown to have overall survival benefit.

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





NCCN has published updates to the NCCN Guidelines, the NCCN Compendium, the NCCN Radiation Therapy Compendium™, and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), for Cervical Cancer. These NCCN Guidelines are currently available as Version 1.2022.

Link directly to the Updates section of the NCCN Guidelines:
Cervical Cancer

• Persistent or recurrent disease (CERV-10)
  • Under “Workup” two new bullets added:
    • Consider comprehensive genomic profiling (CGP) via a validated and/or FDA approved assay
    • If tissue biopsy of metastatic site is not feasible or tissue not available, consider CGP via a validated plasma ctDNA assay
• Principles of Pathology (CERV-A)
  • Pathologic assessment
    • New sub-bullet added: Recommend PD-L1 testing for patients with recurrent, progressive, or metastatic disease
    • Sub-bullet revised: Recommend MMR/MSI; or PD-L1, and/or NTRK gene fusion testing for patients with recurrent, progressive, or metastatic disease; and/or NTRK gene fusion testing for patients with cervical sarcoma.
  • Neuroendocrine Carcinoma of the Cervix
    • Histologic description; 4th Sub-bullet revised: Resembles counterpart in lung This carcinoma type morphologically resembles neuroendocrine carcinomas of the lung.
    • Immunohistochemistry
      • Small cell NECC is variably positive for chromogranin, CD56 and synaptophysin, and PGP9.5.
• Principles of Imaging (CERV-B)
  • Initial Workup
    • Stage I: This section was extensively revised.
    • Stage II-IVA
      • First arrow sub-bullet revised: Consider Pelvic MRI with contrast to assess local disease extent (preferred).
      • Sub-bullet removed: Consider pelvic MRI with contrast to assess local disease extent.
  • Small Cell NECC: This section was extensively revised.
• Principles of Radiation Therapy (CERV-D)
  • Intraoperative Radiation Therapy: "... IORT is typically delivered with electrons, brachytherapy, or miniaturized x-ray sources using preformed applicators of variable sizes..."
  • Treatment Information – Brachytherapy; First bullet: "... MRI immediately preceding or during brachytherapy may be helpful in delineating residual tumor geometry..."
  • Dosing Prescription Regimen – Brachytherapy
    • First bullet revised:  "... nor individual tumor to normal tissue structure correlations. Traditionally point A doses were based on widely validated, dose fractionation for brachytherapy with LDR. The dose at point A assumes an LDR delivery of 40–70 cGy/h. The traditional LDR Point A prescription dose was 70 – 80 Gy. Typical point A prescription doses are 5.5 Gy X 5 fractions for early disease and 6 Gy X 5 fractions for large tumors or those demonstrating a poor response. Another reasonable choice that has been well-studied in European trials for intracavity dosing to the high-risk CTV is 28 Gy in 4 fractions."
    • New bullet added: For brachytherapy in combination with EBRT, the external dose is delivered at 1.8–2.0 Gy per daily fraction. Clinicians using high dose-rate (HDR) brachytherapy use dosing based on the linear-quadratic model equation to convert nominal HDR dose to a biologically equivalent LDR dose. (http://www.americanbrachytherapy.org/guidelines/). The HDR fractionation schedule of 5 fractions delivering 6 Gy nominal dose results in a nominal HDR dose of 30 Gy in 5 fractions, which is generally accepted to be the equivalent to 40 Gy to point A (tumor surrogate dose) using LDR brachytherapy.
    • Bullet removed: The point A dose recommendations provided in the NCCN Guidelines are based on traditional, and widely validated, dose fractionation and brachytherapy at LDRs. In these provided dose recommendations, for EBRT, the dose is delivered at 1.8–2.0 Gy per daily fraction. For brachytherapy, the dose at point A assumes an LDR delivery of 40–70 cGy/h. Clinicians using high dose-rate (HDR) brachytherapy would depend on the linear-quadratic model equation to convert nominal HDR dose to a biologically equivalent LDR dose (http://www.americanbrachytherapy.org/guidelines/). Multiple brachytherapy schemes have been used when combined with EBRT. However, one of the more common HDR approaches is 5 insertions with tandem and colpostats, each delivering 6 Gy nominal dose. This scheme results in a nominal HDR dose of 30 Gy in 5 fractions, which is generally accepted to be the equivalent to 40 Gy to point A (tumor surrogate dose) using LDR brachytherapy. Another reasonable choice that has been well-studied in European trials for intracavity dosing to the high-risk CTV is 28 Gy in 4 fractions.
• Systemic Therapy for Cervical Cancer (CERV-F)
  • Squamous Cell Carcinoma, Adenocarcinoma, or Adenosquamous Carcinoma
    • First-line Combination Therapy; Preferred Regimens: The following were added:
      • Pembrolizumab + cisplatin/paclitaxel ± bevacizumab for PD-L1–positive tumors (category 1)
      • Pembrolizumab + carboplatin/paclitaxel ± bevacizumab for PD-L1– positive tumors (category 1)
    • Column header clarified as Second-line or Subsequent Therapy
      • Preferred regimens: Nivolumab for PD-L1 positive tumors was added
      • Other Recommended Regimens: Tisotumab vedotin-tftv was added
  • Footnote c revised: If not used previously, these agents can be used as second-line or subsequent therapy as clinically appropriate.
  • Footnote f revised: Recommended for disease progression on or after chemotherapy in patients whose tumors express PD-L1 (CPS ≥1) as determined by an FDA-approved test.
  • Footnote h revised: "... as determined by an a validated and/or FDA-approved test, that have progressed following prior treatment and who have no satisfactory alternative treatment options.
  • Footnote k revised: "...may be used as second-line or subsequent therapy for small cell neuroendocrine carcinoma if not used previously.
• Principles of Gynecologic Survivorship (CERV-G)
  • Psychosocial effects revised: Psychosocial effects after cancer may include be psychological (eg, depression, anxiety, fear of recurrence, altered body image), financial (eg, return to work, insurance concerns), and/or interpersonal (eg, relationships, sexuality, intimacy) effects in nature.
    • Clinical approach
      • 1st bullet: "...focuses on managing chronic disease management, monitoring of cardiovascular risk factors, providing recommended vaccinations..."
      • 2nd bullet: "...physical examination, and conduct provide any necessary imaging and/or laboratory testing. All women patients, whether sexually active or not, should be asked about genitourinary symptoms, including vulvovaginal dryness...
      • New bullet added: For premenopausal patients, hormone replacement therapy should be considered."

NCCN has published updates to the NCCN Chemotherapy Order Templates (NCCN Templates^®) for Bladder Cancer to reflect the currently published NCCN Guidelines for Bladder Cancer v5.2021.

• The following NCCN Template^® has been DELETED:
  • BLA5: CMV (CISplatin/Methotrexate/VinBLAStine)

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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