eBulletin Newsletter

NCCN Flash Updates: NCCN Guidelines

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®), and the NCCN Drugs and Biologics Compendium (NCCN Compendium^®) for Management of Immunotherapy-Related Toxicities. These NCCN Guidelines^® are currently available as Version 1.2022.

 Link directly to the Updates section of the NCCN Guidelines: Management of Immunotherapy-Related Toxicities

Management of Immune Checkpoint Inhibitor-Related Toxicities

IMMUNO-1

• Pre-Therapy Assessment
  • Clinical, 2nd bullet revised: Comprehensive Patient and relevant family history of any autoimmune/organ-specific disease, endocrinopathy, or infectious disease.
• Monitoring frequency
  • Pituitary/adrenal revised: Consider repeating prior to each treatment or every 4–6 weeks during immunotherapy (IO only regimens), then follow-up every 6–12 weeks as indicated
• Evaluation for abnormal findings/symptoms
  • Dermatologic revised: Consider dermatology referral. Monitor affected skin BSA and lesion type....
  • Thyroid revised: Total T3 and free T4 if abnormal thyroid function suspected. See ICI_ENDO-2 and ICI_ENDO-3
  • Pituitary/adrenal revised by adding: Cosyntropin stimulation test as indicated.
  • Musculoskeletal revised: creatine phosphokinase (CPK) creatine kinase (CK)
• Footnote c was added: For regimens that require steroid premedication, routine surveillance is not recommended.

IMMUNO-2

• Bullous dermatitis revised from: "The most common immune-related adverse event (irAE) reported is bullous pemphigoid" to "The most common immune-related bullous dermatitis is bullous pemphigoid."
• Thyrotoxicosis due to thyroiditis revised: If symptoms do arise, may include uncommonly, tachycardia, tremor, anxiety, enlarged and tender thyroid gland (rarely).
• Hypophysitis revised by adding: nausea/emesis, fatigue, muscle weakness, may have low blood pressure

IMMUNO-3

• Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) symptoms revised by adding: joint pain typically inshoulders and hips
• Guillain-Barré syndrome (GBS) symptoms revised: ...ascending muscle weakness...
• Vision Changes symptoms revised by adding: ... new floaters, itchy eyes...

Infusion-related reactions

ICI_INF-1

• Mild (G1) bullet 3 and moderate (G2) management, bullet 4 revised: Consider premedication with acetaminophen, H2 blockers famotidine, and diphenhydramine with future infusion

Cardiovascular adverse event(s)

ICI_CARDIO-1

• Cardiovascular Adverse Event(s) revised: Suspected myocarditis/pericarditis/vasculitis
• Symptoms/signs
  • 2nd bullet revised: Conduction abnormalities/heart block
  • 7th bullet,
    • Sub-bullet added: Pulmonary embolism (PE); malignant involvement
    • Sub-bullet removed: Vasculitis
    • 3rd sub-bullet revised: Other infectious etiologies, COVID-19, post-vaccinations AEs
• Assessment/Grading
  • 4th bullet revised: Echocardiogram (if possible with LV strain measurement)
  • 6th bullet, sub-bullet moved to footnote e: Consider ESR, CRP, or other inflammatory markers
• Myocarditis Management
  • 3rd bullet, 1st sub-bullet revised: If responding and stable, switch to oral prednisone (1 mg/kg/day), then taper slowly over 4–6 6–12 weeks based on clinical response and improvement of biomarkers
  • 4th bullet revised: If no improvement within 24–48 hours on steroids, consider adding other potent immunosuppressive agents further interventions:
    • Sub-bullet added: Plasmapheresis
• Pericarditis/Pericardial effusion Management: 2nd bullet revised: If myocarditis not present, manage as per usual recommendations
• Footnotes
  • Footnote d revised by adding: Also, consider high sensitivity troponin and NT pro BNP at baseline and serially during treatment to detect abnormal blood biomarkers that may precede symptomatic myocarditis induced by ICI.
  • Footnote f revised from "No evidence specific to immunotherapy-related myocarditis; recommendations drawn from other causes of myocarditis" to "Use of multiparameter tissue characterization, including T1 and T2 mapping and application of modified Lake Louise Criteria provides important diagnostic value for myocarditis. If cardiac MRI is negative or myocarditis is highly suspected, consider endomyocardial biopsy."
  • Footnote l added: Adler Y, et al. Eur Heart J 2015;36:2921-2964

Dermatologic adverse event(s)

ICI_DERM-1

• Maculopapular rash
  • Assessment/Grading, 4th bullet added: Eosinophil count, peripheral blood smear, and liver function tests with corresponding footnote b, "These features can be used to assist with the diagnosis of DRESS (drug rash with eosinophilia and systemic symptoms) syndrome. This syndrome is typically characterized by a maculopapular rash that involves the face and ears and typically presents with swelling of the face and hands."
  • Management
    • Moderate (G2), 5th bullet revised: If unresponsive to topical within 1 week,..

ICI_DERM-2

• Pruritus management
  • Mild (G1), 3rd bullet revised: ...topical steroids to affected areas or lidocaine patches for localized pruritus
  • Moderate (G2), 5th bullet added: Consider narrow-band UVB phototherapy for refractory cases
  • Severe (G3), 5th bullet revised: Consider aprepitant, dupilumab, or omalizumab, or narrow-band UVB therapy for refractory cases
• Footnote n removed: If outpatient, consider narrow-band UVB phototherapy.

ICI_DERM-3

• Bullous dermatitis management
  • Mild (G1), 1st bullet revised: Consider holding immunotherapy
  • Severe (G3),
    • 1st bullet revised: Permanently discontinue immunotherapy Discontinue immunotherapy
    • 3rd bullet revised: If no improvement after 3 days, consider adding rituximab or IVIG (1 g/kg/day in divided doses per package insert for 3–4 days) IVIG can be considered as an adjunct to rituximab (1 g/kg/day x 2 days with monthly cycle until clear)
    • 5th bullet revised: Urgent dermatology, ophthalmology, and urology consultation
• SJS and TEN management, 5th bullet added: Other immunosuppressive therapies with corresponding footnote x, Immunosuppressive therapies (ie, IVIG, etanercept, cyclosporine) can be considered...the risk of infection should be weighed against the potential benefits of immunosuppression.

Endocrine adverse event(s)

ICI_ENDO-1

• Hyperglycemia diagnosis/workup and management was extensively revised.

ICI ENDO-3

• Footnote p added: Thyrotoxicosis in this setting is usually from...but sometimes resolves to normal with long-term follow up.

ICI_ENDO-4

• Footnote u, 2nd sentence revised from, "Some studies suggest increased mortality in patients treated with high-dose steroids for hypophysitis" to "High-dose steroids do not reverse the likelihood of permanent hormone deficit."

Fatigue

ICI_FTG-1

• Management
  • Moderate (G2)
    • 3rd bullet revised: If no treatable cause found, may consider a trial a short course (2 weeks) of low-dose steroids
    • 4th bullet added: Consider a pause in immunotherapy to assess for improvement in fatigue

Gastrointestinal Toxicity

ICI_GI-1

• Diarrhea and Colitis, Mild (G1)
  • Assessment/grading for Mild (G1), Moderate (G2), and Severe (G3) separated
  • Assessment/grading
    • 1st bullet revised: Consider stool evaluation to rule out infectious etiology
      • Sub-bullet removed: Viral pathogens testing when available (also for ICI_GI-2 and ICI_GI-3)
      • 2nd sub-bullet revised: ...amplification tests (NAATs) for GI pathogens(other bacteria, virus) /bacterial culture (also for ICI_GI-2 and ICI_GI-3)
      • 3rd sub-bullet revised: In appropriate clinical context, consider ova & parasites;...Cyclospora/isospora spp (also for ICI_GI-2 and ICI_GI-3)
    • 2nd bullet revised: ... consider fecallactoferrin/calprotectin (also for ICI_GI-2 and ICI_GI-3)
    • Bullet removed: Infectious disease screening (HIV; hepatitis A, B, C) as clinically indicated
  • Management
    • 2nd bullet revised: Consider loperamide or diphenoxylate/atropine for 2–3 days as an adjunct for symptom relief
    • 5th bullet, 2nd sub-bullet revised: If negative and no infection, continue G1 management and consider adding mesalamine and/or cholestyramine as needed
    • 6th bullet added: Dietary modifications
  • Footnote combined: Consider endoscopy exam within 2 weeks if either lactoferrin or calprotectin is positive. Serial monitoring of calprotectin levels while on treatment (every 2 months) may be helpful to guide treatment duration until achieving endoscopic remission. (Also on ICI_GI-2 and ICI_GI-3)
  • Footnote f revised by adding: or other colitis-related life-threatening conditions. (also ICI-G-3)
  • Footnote i revised by adding: Eg, stool frequency, consistency, blood in stool, nocturnal symptoms, weigh trend. (also for ICI_GI-2 and ICI_GI-3)
  • Footnote j added: Consider avoiding lactose-containing products, BRAT (bananas, rice, apple sauce, toast) diet.

ICI_GI-2

• Diarrhea and Colitis, Moderate (G2)
  • Assessment/grading
    • Bullet moved to footnote r and revised: Obtain  Performinfectious disease screening (HIV; hepatitis A, B, C) and TB test before receiving administering first dose of infliximab or vedolizumab. In urgent situations, treatment does not need to be held for results. (also ICI_GI-3)
  • Management
    • 2nd bullet added: For pathologically confirmed microscopic colitis, consider budesonide 9 mg daily prior to systemic steroids
    • 4th bullet, sub-bullet revised: Consider tofacitinib or ustekinumab for infliximab- and/or vedolizumab-refractory colitis (also ICI_GI-3)
  • Footnotes
    • Footnote c was revised: If positive lactoferrin, strongly recommend early endoscopy or flexible sigmoidoscopy with biopsy within first 2 weeks of the onset of symptoms. Check calprotectin every 2 months to monitor trend and guide treatment. Stop treatment upon return to normal/negative. Consider endoscopy exam within 2 weeks if either lactoferrin or calprotectin is positive. Serial monitoring of calprotectin levels...
    • Footnote l added: In cases with high suspicion for complications (eg, toxic megacolon, abscess or perforation). (also ICI_GI-3)
    • Footnote m added: Hughes M, et al. J Immunother Cancer 2019;7:292.
    • Footnote o revised by adding: If strong clinical suspicion for ICI diarrhea, start empiric IV steroids while waiting for EGD/colonoscopy/flexible sigmoidoscopy results. (also ICI_GI-3)
    • Footnote p revised: Repeat endoscopy and/or fecal calprotectin to assess endoscopic healing may be helpful to guide colitis treatment duration... (also ICI_GI-3)
    • Footnote s added: Infliximab antibody testing is generally not recommended and should not delay switch of therapy. (also ICI_GI-3)
    • Footnote t revised: Consider tofacitinib for infliximab- or vedolizumab-refractory colitis Esfahani K, et al. N Engl J Med 2020;382;2374-2375; Thomas A, et al. N Engl J Med 2021;384:581-583. (also ICI_GI-3)

Gastrointestinal Toxicity

ICI_GI-4

• Hepatic Adverse Event(s)
  • Transaminitis was changed to ALT/AST (also for ICI_GI-5)
    • Assessments/grading
      • 2nd bullet revised: Abdominal ultrasoundcontrast enhanced CT/MRI
      • Bullet removed: Consider GI/hepatology evaluation
    • Management, Moderate (G2), 3rd bullet, sub-bullet added:If liver enzymes do not improve after 3 days, treat as G3.
  • Footnote s removed: Elevated alanine transaminase (ALT) and aspartate transaminase (AST). (also for ICI_GI-5)
  • Footnote w revised: Viral etiology may include hepatitis A/B/C/E; CMV; EBV; HSV, VZV; HIV, anti-HAV IgM, HBsAg, anti-HBc, and HCV-RNA. (also for ICI_GI-5)
  • Footnote x revised: ... tissue transglutaminase IgA and IgG, TSH, iron, and transferrin, HbA1c, and lipid panel (screening for metabolic dysfunction-associated fatty liver disease). (also for ICI_GI-5)

ICI_GI-5

• Removed: “Grade >1 transaminitis with elevated bilirubin (unless Gilbert syndrome)”
• Revised: Elevated ALT/AST, Severe (G3) >5–20 x ULN, Life-threatening (G4) >20 x ULN, Concomitant elevated bilirubin increases risk of hepatic failure (unless Gilbert Syndrome)
• Assessment/grading
  • 2nd bullet added: Consider other etiologies including myositis
  • 3rd bullet revised: Consider GI/hepatology evaluation
  • Life-threatening (G4)
    • 1st sub-bullet revised: If steroid refractory or no improvement after 3 1–2 days, consider adding mycophenolate
    • Sub-bullet added: If no improvement on mycophenolate, consider ATG
    • Bullet removed: Hepatology consultation
• Management
  • Severe (G3)
    • 2nd bullet revised: Initiate prednisone/methylprednisolone 1–2 mg/kg/day
      • Sub-bullet revised: If steroid refractory or no improvement after 3 1–2 days, consider adding mycophenolate
      • Sub-bullet added: If no improvement on mycophenolate, consider antithymocyte globulin (ATG) (category 2B)
    • Bullet removed: Hepatology consultation
• Footnote bb added: Maximal efficacy of steroid-sparing immunosuppressive therapy (eg, mycophenolate, tacrolimus, ATG, etc.) can be delayed and may require prolonged therapy (≥ 1 week) in the treatment of irAEs.

ICI_GI-7

• Acute pancreatitis
  • Assessment/grading, 4th bullet added: Assess for other causes (ie, alcohol, biliary)

 

Nervous System Toxicity

ICI_NEURO-1

• Myasthenia gravis,
  • Assessment/grading, 4th bullet revised: ESR, CRP, creatinine phosphokinase (CPK), aldolase, and anti-striational antibodies for superimposed myositis
• Footnote i revised: Beta-blockers, ciprofloxacin fluoroquinolones, and IV magnesium.

ICI_NEURO-2

• GBS,
  • Assessment/grading, 7th bullet added: Early electromyography (EMG)/nerve conduction study (NCS) with corresponding footnote, Early EMG/NCS findings may assess potential severity of GBS (Sejvar JJ, et al. Vaccine 2011;29:599-612; Leonhard SE, et al. Nat Rev Neurol 2019;15:671-683).
• Footnote k revised by adding: Consider infectious disease (ID) consult. ID work up: Measure opening pressure and check cell count, protein glucose, Gram stain, culture, PCR for HSV, and other viral PCRs depending on suspicion and cytology. May see elevated WBC with normal glucose, normal culture, Gram stain, and elevated protein. May see reactive lymphocytes or histiocytes on cytology.

ICI_NEURO-4

• Aseptic meningitis
  • Assessment, 2nd bullet revised: Consider lumber puncture if feasible
  • Management, 2nd bullet revised: Consider permanently discontinuing immunotherapy if severe
• Encephalitis management
  • 4th bullet revised: Consider IV acyclovir until HSV 1 and 2 PCR results obtained
  • 6th bullet revised: If severe or progressing symptoms or oligoclonal bands present, if progressing over 24 h, strongly consider pulse steroids...
• Footnote aa revised: Measure opening pressure and check cell count, protein glucose, Gram stain, culture, PCR for HSV, and other viral PCRs depending on suspicion, cytology, and oligoclonal bands. If the patient is encephalopathic, check autoimmune encephalopathy panel.May see elevated WBC with lymphocytic predominance and/ or elevated protein. May see elevated WBC with normal glucose, normal culture, Gram stain, and elevated protein. May see reactive lymphocytes or histiocytes on cytology.
• Footnote ff added: If there is concern for VZV reactivation, also wait for VZV PCR results before stopping acyclovir treatment.

ICI_NEURO-5

• Transverse myelitis,
  • Assessment, 4th bullet revised: ... anti-Ro/La antibodies, TSH, aquaporin-4 IgG, myelin oligodendrocyte glycoprotein (MOG) IgG, paraneoplastic panel for anti-Hu and anti-CRMP5/CV2

Ocular Toxicity

ICI_OCUL-1

• Assessment/grading, 2nd bullet added: Evaluate for other common causes, including infectious disease with corresponding footnote b: Etiologies such as HLA-B27, syphilis, toxoplasmosis, and tuberculosis ..other local therapies.
• Scleritis management added.
• Uveitis qualifiers revised: "Mild Anterior or intermediate uveitis (G1 or G2)" and "Anterior uveitis (G2) Posterior or Pan-uveitis (G3) 20/200 vision (G4)"
  • Management for Anterior or intermediate uveitis (G1 or G2),
    • 1st bullet revised: Continue immunotherapy or hold immunotherapy to observe for worsening uveitis; if uveitis isstable on topical therapy consider restarting immunotherapy in discussion with ophthalmology
    • 2nd bullet added: Treatment guided by ophthalmology to include ophthalmic ± systemic prednisone/ methylprednisolone
• Episcleritis 20/40 vision or better (G2)...
  • 2nd bullet revised: ...ophthalmic NSAID or prednisolone or and systemic prednisone/methylprednisolone
• Footnote a revised: Episcleritis can be associated with red discoloration of the eye. Uveitis can be associated with eye
  • oredness. Both uveitis and episcleritis can be associated with eye redness but slit lamp examination is essential to rule out anterior chamber inflammation.
• Footnote f revised: Treat with 1 mg/kg/day not to exceed 60 mg/day until symptoms...

 

Pulmonary Toxicity

ICI_PULM-1

• Pneumonitis
  • Footnote d added: Consider cardiac etiologies.
  • Footnote j revised: “Immunocompromised panel may include CBC with differential, bacterial culture and Gram stain;... (also for ICI_PULM-2)

ICI_PULM-2

• Footnote p added: MMF is unlikely to improve steroid-refractory pneumonitis immediately but may have a clinical benefit when patients are unable to be weaned from steroids.

Renal toxicity

ICI_RENAL-1

• Footnote h added: Lin JS, et al. Oncoimmunology 2021;10:1877415.

Principles of Immunosuppression

IMMUNO-A (2 of 3)

• Viral reactivation changed to Pathogen reactivation,
  • 3rd bullet added: For individuals starting on steroids who were born or who have lived for >3 months in areas endemic for Strongyloides such as Central or South America, Southeast Asia, and Africa, would send Strongyloides IgG serology and either treat for positive serology, or treat empirically with ivermectin 0.2 mg/kg daily x 2 days and repeat in 2 weeks for total of 4 doses.

Principles of Immunotherapy

IMMUNO-B (1 of 3)

• Instruct patients to notify
  • 3rd bullet, sub-bullet revised: Vaccines that are inactivated or killed, or mRNA (eg, COVID vaccines)...

Principles of Immunotherapy Rechallenge

IMMUNO-C (2 of 2)

• Pancreas
  • 1st bullet revised: Symptomatic grade ≤2 3 pancreatitis: Consider resumption of immunotherapy...
  • 2nd bullet revised: Permanent discontinuation is warranted for severe (grade 3-4) pancreatitis.

Management of CAR T-Cell–Related Toxicities

CART-1

• Before and During CAR T-Cell Infusion
  • 1st bullet added: Baseline cardiac assessment, such as echocardiogram. Consult with cardiology if previous cardiac history or concern from assessment.
  • 2nd bullet revised: ...preferably with double or triple lumen catheter, for IV fluid and other infusions in case of toxicities possible vasopressors use.
  • 4th bullet revised: Tumor lysis precautions prophylaxis and monitoring are recommended for patients with large tumor burden...
  • 6th bullet revised: Baseline neurological evaluation, including ICE scores (for adults) or CAPD scores (for children less than 12 years) prior to CAR T-cell therapy. Consider baseline brain MRI.
  • 7th bullet added: Baseline CRP and serum ferritin
• Post-CAR T-Cell Infusion
  • 1st bullet revised: Hospitalization or extremely close outpatient monitoring at centers with transplant or prior outpatient CAR T-cell transplant  experience. Close monitoring in the hospital...
  • 2nd bullet revised: Hospitalization is warranted for patients withat the first sign of CRS or neurotoxicity (including fever, hypotension, or change in mental status) is warranted.
  • 3rd bullet revised: Monitor CBC, CMP (including magnesium and phosphorus), and coagulation profile daily.
  • 4th bullet revised: Baseline CRP and serum ferritin should be rechecked at least 3 times per week for 2 weeks post-infusion. Consider daily checks...
  • 5th bullet revised: Assessment for CRS should be done at least twice daily, Vital signs to allow clinical assessment for CRS should be done at least every 8 hours, or when the patient’s status changes, during the peak window of CRS risk (typically the first 1-2 weeks post-infusion).
  • 6th bullet revised: Neurotoxicity assessment should be done at least twice daily or when the patient’s status changes (typically occurs 1-2 weeks post-infusion, but late onset up to a month or later may occur.) during the peak window of neurotoxicity risk. If neurologic concern develops, more frequent assessments are recommended assess at a minimum of every 8 hours to include cognitive assessment and motor weakness.
  • 7th bullet added: Monitor for CRS, neurotoxicity, and other toxicities for the duration recommended by the CAR product package insert (at least 4 weeks post-infusion for most patients). Patients should refrain from driving or hazardous activities for at least 8 weeks following infusion.

CART-2

• CRS
  • 1st bullet revised: Typical time to onset: 2–3 days; however, CRS may occur as early as hours after infusion and as late as 10-15 days post-infusion
• Neurologic Toxicity
  • 3rd bullet revised: The most common neurologic toxicities include encephalopathy, headache, tremor, dizziness, aphasia, delirium, insomnia, anxiety, and autonomic neuropathy. Agitation, hyperactivity, or signs of psychosis can also occur. Transient neurological symptoms can be heterogeneous and include encephalopathy, delirium, aphasia, lethargy, headache, tremor, myoclonus, dizziness, motor dysfunction, ataxia, sleep disorder (eg, insomnia), and anxiety, agitation and signs of psychosis.
  • 4th bullet revised: Serious events including seizures, depressed level of consciousness, as well as fatal and serious cases...
• Hemophagocytic Lymphohistiocytosis/Macrophage-Activation Syndrome (HLH/MAS) During CRS
  • 1st bullet, 1st sub-bullet revised: Rapidly rising and high ferritin (>5000 ng/mL) with cytopenias in the context of CRS fever, especially if accompanied...
  • Footnote b added: Alvi R, et al. J Am Coll Cardiol 2019;74:3099-3108; Ghosh A, et al. JACC CardioOncol 2020; 2:97-109.

CART-3

• Cytokine Release Syndrome (CRS), 2nd bullet revised: Fever is defined as temperature >38°C... fever is no longer not required to grade subsequent CRS severity. In this case, CRS grading is driven by hypotension and/or hypoxia.
• CRS Grade, Grade 1
  • Anti-IL-6 Therapy revised: For prolonged CRS (>3 days) in patients or those with significant symptoms, and/or comorbidities and/or are elderly...
  • Additional Supportive Care, 1st bullet revised: Sepsis screen and empiric broad-spectrum antibiotics, consider granulocyte colony-stimulating factor...
• CRS Grade, Grade 2
  • Additional Supportive Care, 2nd bullet revised:...other methods of hemodynamic monitoring. Telemetry, EKG, troponin, and BNP if persistent tachycardia.

CART-3A

• Footnote c revised: For HLH/MAS during CRS, treat as per CRS with addition of steroids. If symptoms do not improve within 48 hours, consider etoposide and intrathecal cytarabine for neurotoxicity tocilizumab and steroids, although the suspicion of HLH/MAS should prompt consideration of higher doses of steroids at a given CRS grade. If no improvement is observed within 48 hours, consider addition of anakinra to corticosteroids. Etoposide or intrathecal cytarabine can be considered as a last resort for HLH with CNS involvement.
• Footnote l added: Per the prescribing information for axicabtagene ciloleucel, consider the use of prophylactic corticosteroids in patients after weighing the potential benefits and risks. Steroid prophylaxis for axicabtagene ciloleucel is dexamethasone 10 mg orally once daily for 3 days with the first dose starting pre-CAR T-cell infusion.
• Footnote p revised: Other agents such as anakinra, siltuximab, ruxolitinib, cyclophosphamide, IVIG, ATG, or extracorporeal cytokine adsorption with...

CART-5

• Footnote w revised: Diagnostic lumbar puncture for grade 3–4 neurotoxicity; consider for grade 2. Patients should undergo assessment for papilledema or other signs of elevated intracranial pressure. If elevated intracranial pressure is excluded, a diagnostic lumbar puncture may be considered for patients with grade 3-4 neurotoxicity.
• Footnote x added: If dexamethasone is used for prophylaxis of CRS, there may be an increased risk of grade 4 and prolonged neurologic toxicities.

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.

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