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^®), the NCCN Drugs and Biologics Compendium (NCCN Compendium^®), and the NCCN Chemotherapy Order Templates (NCCN Templates^®) for Multiple Myeloma. These NCCN Guidelines^® are currently available as Version 3.2022. 

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

Updates in version 3.2022

• Therapies for Patients with Late Relapses (> 3 prior therapies) (MYEL-G 4 of 4)
  • The regimen melphalan flufenamide/dexamethasone was removed.
• The following template has been DELETED:
  • MUM103: Melphalan flufenamide/Dexamethasone

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 and the NCCN Compendium^® for Non-Small Cell Lung Cancer (NSCLC). These NCCN Guidelines^® are currently available as Version 7.2021.

• NSCL-3 
  • Footnote q modified: Test for EGFR mutation (stages IB-IIIA) and PD-L1 status (stages II-IIIA) on surgical tissue or biopsy. (also applies to NSCL-6 and NSCL-7)
• NSCL-4
  • Atezolizumab added for patients with completely resected stage IIB-IIIA or high-risk stage IIA PD-L1 ≥1% NSCLC who received previous adjuvant chemotherapy. (also applies to NSCL-6 and NSCL-7)
  • Footnote w added: For patients with PD-L1 ≥1% NSCLC who received previous adjuvant chemotherapy. (also applies to NSCL-6 and NSCL-7)
• NSCL-E 1 of 2
  • Previous Adjuvant Chemotherapy, the following added:
    • Atezolizumab 840 mg every 2 weeks, 1200 mg every 3 weeks, or 1680 mg every 4 weeks for up to 1 year
    • Atezolizumab for patients with completely resected stage IIB-IIIA or high-risk stage IIA PD-L1 ≥1% NSCLC who received previous adjuvant chemotherapy.
• NSCL-E 2 of 2
  • Reference added: Felip E, Altorki N, Zhou C, et al. Adjuvant atezolizumab after adjuvant chemotherapy in resected stage IB–IIIA non-small-cell lung cancer (IMpower010): a randomised, multicentre, open-label, phase 3 trial. Lancet 2021;398:1344-1357.

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 Testicular Cancer. These NCCN Guidelines are currently available as Version 1.2022. 

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

• Workup (TEST-1)
  • Footnote a modified: Though rare, when a patient presents with rapidly increasing beta-hCG or AFP and symptoms related to disseminated disease with a testicular mass, chemotherapy can be initiated immediately without waiting for a biopsy diagnosis or performing orchiectomy. However, orchiectomy should be performed at completion of chemotherapy.
• Pathologic Diagnosis (TEST-2)
  • Footnote removed: With contrast.
  • Footnote j modified: Elevated values should be followed after orchiectomy with repeated determination to allow precise staging. Follow declining markers until normalization or plateau nadir. (Also for Test-6)
  • Footnote l modified: Eg, beta-hCG >5000 IU/L, non-pulmonary visceral metastases, or extensive lung metastasis, or neurologic symptoms present.
• Primary Treatment (TEST-4)
  • Modified: Primary chemotherapy (preferred)
• Post Chemotherapy Management (TEST-5)
  • Modified: Repeat PET/CT or CT scan in 6–8 weeks
  • Follow-Up
    • Modified: Consider 2 cycles adjuvant chemotherapy
• Primary Treatment (TEST-7)
  • Footnote oo added: Recommend referral to a high-volume centers should be considered. (Also for TEST-8 and TEST-9)
• Primary Treatment (TEST-8)
  • Footnote pp modified: RPLND is preferred as primary treatment for stage II tumors with somatic type malignancy stage II tumors with (previously referred to as transformed teratoma), and should be considered for stage II tumors with teratoma predominance in patients with normal markers.
  • Footnote added: RPLND should be considered for stage II tumors with teratoma predominance in patients with normal markers.
  • Footnote rr added to page and modified: Patients who are at higher risk for bleomycin-related complications. Bleomycin-based regimens should not be given to patients > 50 years of age, those at risk for pulmonary complications, those with underlying lung disease, etc. (Also for TEST-9, -10, and -11)
• Post-Chemotherapy Management (TEST-9)
  • Modified: Negative markers, no mass <1 cm (transaxial long axis) on CT scan
  • Modified: Negative markers, no mass ≥1 cm (transaxial long axis) on CT scan
  • Footnote added: Craniocaudal axis should not be used. 
  • Footnote removed: Referral to high-volume centers should be considered for surgical resection of masses post-chemotherapy.
• Postsurgical Management (TEST-10)
  • Surveillance (preferred) or Chemotherapy: 
    • Removed: BEP for 2 cycles or
  • Chemotherapy (preferred):
    • Removed: BEP for 2 cycles or
  • pN1, pN2:
    • Removed: Other Recommended Regimens;  BEP=Bleomycin/etoposide/cisplatin
  • Footnote uu added: This is a rare circumstance. BEP for 2 cycles is an option.
• Primary Treatment (TEST-11)
  • Modified: Primary chemotherapy for poor-risk disease ± RT ± surgery, if clinically indicated. 
  • Footnote vv modified: To assess response after treatment, CT with contrast of chest/abdomen/pelvis and any other sites of disease is recommended. PET has no role in assessing treatment response and residual masses following chemotherapy in patients with nonseminoma. (Also for TEST-13, -14, and -15)
• Response after Primary Treatment (TEST-12)
  • Footnote xx added: Consider brain imaging and testicular ultrasound in patients with elevated or rising markers after primary or secondary chemotherapy to evaluate for occult brain metastases or contralateral primary disease.
• Third-Line Therapy (TEST-15)
  • Modified: MSI/MMR or TMB testing if progression after high-dose chemotherapy or third-line therapy.
• Follow-Up for Seminoma (TEST-A 1 of 2)
  • Table 1, Abdominal ± Pelvic ± CT:
    • Modified Year 1: At 3, 4–6, and 12 mo.
  • Footnote e modified: In select circumstances, a An MRI can be considered to replace an abdominal/pelvic CT. The MRI protocol should include all the nodes that need to be assessed. The same imaging modality (CT or MRI) should be used throughout surveillance.
• Follow-Up for Seminoma (TEST-A 2 of 2)
  • Table 3, Abdominal ± Pelvic CT:
    • Modified Year 1: At 3 mo, then at 6-12 9 or 12 mo
• Follow-Up for Nonseminoma (TEST-B 1 of 3)
  • Table 5, Chest x-ray:
    • Modified Year 5: Annually As clinically indicated
  • Footnote d modified: In select circumstances, a An MRI can be considered to replace an abdominal/pelvic CT. The MRI protocol should include all the nodes that need to be assessed. The same imaging modality (CT or MRI) should be used throughout surveillance.
• Follow-Up for Nonseminoma (TEST-B 2 of 3)
  • Footnote k revised: For patients with unresectable unresected residual masses or resected residual masses containing viable cancer.
  • Footnote l added: Consider annual tumor markers for years 5–10.
• Principles of Radiotherapy for Pure Testicular Seminoma (TEST-C 1 of 5)
  • Second bullet modified: As a result, the risk of second cancers arising in the kidneys, liver, or bowel may be lower with 3D-CRT than IMRT, and IMRT is not recommended necessary.
• Risk Classification for Advanced Disease (TEST-D)
  • Footnote b added: Newer risk model to give prognostic information can be used through nomogram: https://eortc.shinyapps.io/IGCCCG-Update/ (Gillessen S, et al. J Clin Oncol 2021:39:1563-1574).
  • Footnote d added: Patients with good-risk disseminated seminoma with an LDH >2.5 x ULN have a worse prognosis than other good-risk patients. However, there are insufficient data at this time to recommend treating these patients differently based on LDH.
• Third-Line Chemotherapy Regimens for Metastatic Germ Cell Tumors (TEST-G 1 of 3)
  • Footnote added: Tumor mutational burden-high (TMB-H) [≥10 mutations/megabase (mut/Mb)] tumors, as determined by a validated and/or FDA-approved CGP assay. (Also for TEST-G 2 of 3)
• Principles of Surgery for Germ Cell Tumors (TEST-H 1 of 2)
  • Testis-Sparing Surgery (TSS)
    • First sub-bullet, second sub-bullet modified: Non-palpable testicular masses <2 cm are associated with benign tumors in up to 80% of patients, and therefore, TSS may be considered in these patients in whom TSS is technically feasible. to avoid orchiectomy in patients with benign tumors.
• Principles of Surgery for Germ Cell Tumors (TEST-H 2 of 2)
  • Postchemotherapy Setting
    • Fifth bullet modified: Limited data suggest increased frequency of aberrant recurrences with the use of minimally invasive laparoscopic or robotic approaches to RPLND. Therefore, minimally invasive RPLND is not recommended as standard management at this time, but can be considered in highly selected cases at high-volume centers.

NCCN has published updates to the NCCN Templates^® for Non-Small Cell Lung Cancer to reflect the currently published NCCN Guidelines for Non-Small Cell Lung Cancer v 7.2021.

• Changes to the Indication section have been made on the following NCCN Template^®:
  • NSC103: Atezolizumab
• References have been updated on the following template:
  • NSC103: Atezolizumab
• Changes to the Chemotherapy Regimen section have been made on the following template:
  • NSC103: Atezolizumab
• Drug information notes for the following agent have been updated in the Supportive Care, Monitoring and Hold Parameters, and/or Safety Parameters and Special Instructions sections:
  • Atezolizumab

NCCN has published updates to the NCCN Templates for Hairy Cell Leukemia to reflect the currently published NCCN Guidelines for Hairy Cell Leukemia v1.2022.

• References have been updated for the following templates:
  • HCL2: Pentostatin
  • HCL9: Ibrutinib
  • HCL10: Vemurafenib + RiTUXimab
• Changes to the Indication section have been made on the following templates:
  • HCL10: Vemurafenib + RiTUXimab
  • HCL11: Vemurafenib
• Changes to the Chemotherapy Regimen section have been made on the following templates:
  • HCL3: Cladribine + RiTUXimab
  • HCL4: Pentostatin + RiTUXimab
  • HCL6: RiTUXimab
  • HCL10: Vemurafenib + RiTUXimab
• The following notes have been deleted in the Other Supportive Therapy section on all templates:
  • Consider bacterial prophylaxis (quinolone or equivalent) during periods of neutropenia.
  • Consider pneumocystis jiroveci pneumonia (PJP) prophylaxis with sulfamethoxazole/trimethoprim or equivalent for a minimum of 3 months AND until CD4 >200 cells/mm3 following completion of therapy.
  • Consider herpes virus prophylaxis (acyclovir or equivalent) for a minimum of 3 months AND until CD4 >200 cells/mm3 following completion of therapy.
• The following note has been deleted in the Monitoring and Hold Parameters section on the following templates:
  • CBC with differential should be monitored as clinically indicated for potential dose modifications.
    • HCL9: Ibrutinib
    • HCL12: Moxetumomab pasudotox-tdfk

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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