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NCCN Flash Updates: NCCN Guidelines Updated for Ovarian Cancer

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®), the NCCN Drugs & Biologics Compendium (NCCN Compendium^®), and the NCCN Radiation Therapy Compendium™ for Ovarian Cancer. These NCCN Guidelines^® are currently available as Version 1.2024.

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

General

• 'Clinical trial' recommendations listed in the algorithm and footnotes have been removed due to the clinical trial recommendation noted at the bottom of each page
• Mucinous Carcinoma of the Ovary has been changed to Mucinous Neoplasms of the Ovary
• Ovarian Borderline Epithelial Tumors has been changed to Ovarian Serous Borderline Epithelial Tumors

OV-1

• Workup
  • Footnote modified: ImagingCTis performed with oral and IV contrast (unless contraindicated) and rectal contrast as needed. (Also for OV-3, OV-5, OV-6, LCOC-7, LCOC-10, LCOC-13)
  • Footnote modified: Other tumor markers may include inhibin, beta-human chorionic gonadotropin (β-hCG), alpha-fetoprotein, lactate dehydrogenase (LDH), carcinoembryonic antigen (CEA), and CA 19-9, and HE4. (Also for OV-3)

OV-5

• Maintenance Therapy
  • Footnote g removed from niraparib and added to Maintenance Therapy header: In the absence of a BRCA1/2 mutation, HRD status may provide information on the magnitude of benefit of PARPi therapy (OV-B).
  • No bevacizumab used during primary therapy; Germline or somatic BRCA1/2 mutation; CR/PR
    • Recommendation revised: Consider observation for stage II disease onlyObserve for select stage II disease with CR
  • Bevacizumab used as part of primary therapy
    • Bevacizumab + niraparib (if unable to tolerate olaparib) added as a category 2A recommendation

OV-6

• Recurrent Disease
  • Footnote modified: ...Tumor molecular analysis is recommended to include, at a minimum, tests to identify potential benefit from targeted therapeutics that have tumor-specific or tumor-agnostic benefit including, but not limited to, HER2 status (by IHC), BRCA1/2, HRD status, microsatellite instability (MSI), mismatch repair (MMR), tumor mutational burden (TMB), BRAF, FRα (FOLR1),... (Also for OV-7, OV-8, LCOC-7, OV-C 8 of 12, OV-C 9A of 12)

OV-7

• Footnote ee revised: Definitions of platinum-sensitive and platinum-resistant disease are impreciserepresent a spectrum of disease; clinical judgment and flexibility should be utilized in determining treatment options. (Also for OV-8)
• Footnote modified: Palliative localized radiation therapy (RT) can be considered.Localized radiation therapy (RT) can be considered to palliate symptoms and/or for oligometastatic disease. (Also for OV-8, LCOC-11, LCOC-13, LCOC-14)

OV-8

• Recurrence Therapy for Platinum-Sensitive Disease
  • Biochemical relapse (rising CA-125 and no radiographic evidence of disease)
    • Options have been broken into two pathways
    • Text revised: Delay treatment until radiographic and/or clinical relapse
    • Arrow added to start of top pathway from radiographic and/or clinical relapse
  • Maintenance therapy text revised:
    • PARPi therapy (for those with BRCA 1/2 mutation):if not previously used (category 1 for BRCA mutation carriers)
      • If not previously used (category 1)
      • If disease has not progressed during prior PARPi treatment

OV-8

• Footnote kk revised: PARPi options include niraparib, olaparib, or rucaparib in patients with BRCA-mutated platinum-sensitive disease who have completed two or more lines of platinum-based therapy.For patients with platinum-sensitive disease who have completed two or more lines of platinum-based therapy. Olaparib may be used regardless of BRCA status (preferred for those with a BRCA mutation).Based on FDA indication, niraparib is limited to those with a deleterious or suspected deleterious germline BRCA mutation. Based on FDA indications, olaparib and rucaparib isare limited to those with a deleterious or suspected deleterious BRCA mutation (germline or somatic). Caution should be used when using maintenance PARPi for longer than 24 months. There are limited data on the use of a maintenance PARPi in patients who previously received a PARPi or after recurrence therapy with bevacizumab. Combination bevacizumab/PARPi is not recommended at this time for maintenance after recurrence therapy.

LCOC-4

• Mucinous Neoplasms of the Ovary
  • 'Carcinoma' added to Stage IA-IB, Stage IC, and Stage II-IV
  • Borderline
    • Adjuvant treatment revised: See LCOC-8Observe

LCOC-5

• Grade 1 endometrioid carcinoma
  • Stage IC and Stage II-IV
    • Goserelin acetate added as an option for hormonal therapy (Also for LCOC-6, LCOC-A, OV-C 5 of 12, OV-C 6 of 12, OV-C 8 of 12, OV-C 9 of 12)

LCOC-6

• Low-Grade Serous Carcinoma
  • Stage IC and Stage II-IV
    • Maintenance letrozole changed from a category 2B to a category 2A recommendation
    • Tamoxifen removed as a hormonal therapy option for Low-Grade Serous Carcinoma only
    • Footnote removed: Other hormonal therapy options include: aromatase inhibitors (ie, anastrozole, exemestane), leuprolide acetate, and tamoxifen.
    • Footnote added: Other hormonal therapy options include: aromatase inhibitors (ie, anastrozole, exemestane), leuprolide acetate, and goserelin acetate.

LCOC-7

• Recurrence Therapy
  • Footnote u modified: An aromatase inhibitor (ie, letrozole, anastrozole, exemestane) is preferred if not used previously. Fulvestrant, tamoxifen, or leuprolide acetate, or goserelin acetate is recommended if an aromatase inhibitor was given previously.

LCOC-10

• Ovarian Serous Borderline Epithelial Tumors
  • Monitoring/Follow-up
    • Bullet 1 revised: Visits every 3–63–12 mo for up to 5 y, then as clinically indicatedannually
  • Recurrent Disease
    • Disease name modified: Low-grade serous carcinoma or Low-grade invasive carcinoma
      • Recurrence therapy for low-grade invasive carcinoma modified: See low-grade serous epithelial carcinoma (See LCOC-6)See appropriate LCOC page based on histology (LCOC-1)
    • Disease name modified: High-grade invasive carcinoma (high-grade)

LCOC-11

• Malignant Sex Cord-Stromal Tumors
  • Adjuvant Treatment
    • Stage II-IV: Platinum-based chemotherapy changed from a category 2B to a category 2A recommendation

LCOC-13 & LCOC-14

• LCOC-13 has been extensively revised and broken apart with creation of a new page: LCOC-14
  • Monitoring/Follow-up
    • Pathway modified for residual tumor on radiographic imaging; markers normal: Biopsy or Consider surgical resection or Observe
  • Therapy for Recurrent/Persistent Disease
    • Complete clinical response, pathway revised: Consider additionalSecond-line chemotherapy (category 2B) or High-dose chemotherapy + HCT (category 2B) or Consider surgery for select patients
    • Residual malignancy, pathway revised with removal of "Consider additional platinum-based chemotherapy x 2 cycles" and arrow added to "TIP (paclitaxel/ifosfamide/cisplatin) or High-dose chemotherapy + hematopoietic cell transplant (HCT) (strongly recommend referral to tertiary care center for potentially curative regimen)" instead
  • Footnote ii revised: Pediatric/adolescent patients with the following clinical presentations may consider observation or chemotherapy as treatment options: stage IA, IB dysgerminoma; stage IA, grade 1 immature teratoma; stage IA embryonal carcinomas; or stage IA yolk sac tumors. Consultation with a pediatric oncologist for pediatric/adolescent patients is recommended.There are ongoing studies evaluating observation for stage IA and IB, grade 2/3 pure immature teratomas (may contain microscopic foci of yolk sac tumor), yolk sac tumor, embryonal carcinoma, and choriocarcinoma (pure or mixed) in adults.

LCOC-A

• Systemic Therapy Regimens
  • Malignant Germ Cell Tumors, Primary Therapy
    • Useful in Certain Circumstances
      • Etoposide/carboplatin, stage modified: (for select patients with stage IBII–III resected dysgerminoma for whom minimizing toxicity is critical)
        • Footnote added to regimen: Consultation with a pediatric oncologist for pediatric/adolescent patients is recommended.

OV-A 2 of 4

• Principles of Surgery
  • First header modified: Newly Diagnosed Invasive Epithelial Ovarian Cancer Apparently Confined to an Ovary or to the Pelvis (apparent stage IA–IIA)Newly Diagnosed Invasive Epithelial Ovarian Cancer Apparently Confined to the Ovaries, Fallopian Tubes, and Uterus (apparent stage IA–IIA)
  • Second header: staging modified from stage >IIB to stage >IIB

OV-B 1 of 3

• Principles of Pathology
  • General
    • Bullet 3 modified: ...already had a bilateral oophorectomy salpingo-oophorectomy).
    • Elements from CAP protocol
      • CAP protocol updated to most recent version (2023) (Also for OV-B 2 of 3)
      • Bullet added: Staging information (FIGO and TNM)
    • Bullet 5, sub-bullet 2 modified: In the recurrence setting, tumor molecular analysis is recommended to include, at a minimumas appropriate, tests to identify potential benefit from targeted therapeutics that have tumor-specific or tumor-agnostic benefit including, but not limited to, HER2 status (by IHC),... FRα (FOLR1),....

OV-B 3 of 3

• References have been updated.

OV-C 3 of 12

• Principles of Systemic Therapy
  • Principles of Maintenance PARP Inhibitor (PARPi) Therapy
    • Post Recurrence Treatment, sub-bullet modified: Certain Patients with BRCA-mutated recurrent disease may benefit from maintenance therapy with PARPi after recurrence therapy, if in CR or PR after platinum-based recurrence therapy, and if no prior progression on a PARPi.
  • Niraparib + bevacizumab regimen: Setting, Dose/Administration, and Duration added to table

OV-C 5 of 12

• Primary Therapy for Stage I Disease
  • Regimens updated:
    • Paclitaxel/cisplatin added as a category 2A recommendation under Useful in Certain Circumstances (Also for Stage II-IV on OV-C 6 of 12)
    • Docetaxel/oxaliplatin/bevacizumab + maintenance bevacizumab removed as a treatment option for Stage I disease
  • Mucinous carcinoma
    • Staging language modified: (stage IC, grades 1–3)
  • Low-grade serous (stage IC)/Grade I endometrioid (stage IC)
    • Footnote added for maintenance letrozole: For low-grade serous, maintenance letrozole is a category 2A recommendation. For grade I endometrioid, maintenance letrozole is a category 2B recommendation. (Also for OV-C 6 of 12)
    • Footnote added to tamoxifen: Tamoxifen is not recommended for low-grade serous carcinoma. (Also for OV-C 6 of 12, OV-C 8 of 12, OV-C 9A of 12)

OV-C 6 of 12

• Primary Therapy for Stage II-IV Disease
  • High-grade serous, Endometrioid (grade 2/3), Clear cell carcinoma, Carcinosarcoma
    • IV/IP paclitaxel/carboplatin added as a category 2A recommendation under Useful in Certain Circumstances

OV-C 7 of 12

• Primary Systemic Therapy Recommended Dosing
  • Regimen and dosing added for:
    • Paclitaxel/cisplatin
    • IV/IP Paclitaxel/carboplatin

OV-C 8 of 12

• Recurrence Therapy for Platinum-Sensitive Disease
  • Mirvetuximab soravtansine-gynx/bevacizumab (for FRα-expressing tumors) added as a category 2B recommendation under Useful in Certain Circumstances

OV-C 9 of 12

• Recurrence Therapy for Platinum-Resistant Disease
  • Regimens updated:
    • Cyclophosphamide (oral)/pembrolizumab/bevacizumab added as a category 2A recommendation under Other Recommended Regimens
    • Fam-trastuzumab deruxtecan-nxki (for HER2-positive tumors [IHC 3+ or 2+]) added as a category 2A recommendation under Useful in Certain Circumstances
    • Mirvetuximab soravtansine-gynx/bevacizumab (for FRα-expressing tumors) changed from a category 2B to a category 2A recommendation
  • Footnote * revised: Do not use in platinum-refractory disease.Platinum agents have limited activity when the disease has demonstrated growth through a platinum-based regimen, and platinum rechallenge is generally not recommended in this setting.

OV-C 10 of 12

• References have been updated.

OV-D 1 of 7

• Management of Drug Reactions
  • Bullet 3, sub-bullet 1 revised: Adverse reactions associated with biotherapeutic agents and taxane drugs (ie, docetaxel, paclitaxel) and biotherapeutic agents tend to be infusion-related and, in taxanes, are often attributed to the excipient (ie, Cremophor EL in paclitaxel, polysorbate 80 in docetaxel). cremophor in paclitaxel and These tend to occur during the first few cycles of treatment...

OV-E 1 of 2 & OV-E 2 of 2

• WHO Histologic Classification
  • Tables/terminology have been modified to reflect the most recent version of the WHO (2020)
  • Reference updated: Adhikari L, Hassell LA. World Health Organization Classification of Female Genital Tumours, 5th edition. IARC, 2020.
  • Footnote added: Behavior is coded 0 for benign tumors; 1 for unspecified, borderline, or uncertain behavior; 2 for carcinoma in situ and grade III intraepithelial neoplasia; 3 for malignant tumors, primary site.

 

NCCN has published updates to the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™) for Ampullary Adenocarcinoma. These NCCN Guidelines^® are currently available as Version 1.2024.

 

 

NCCN has published updates to the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™) for Prostate Cancer Early Detection. These NCCN Guidelines^® are currently available as Version 1.2024.

 

NCCN has published updates to the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™) for Pancreatic Adenocarcinoma. These NCCN Guidelines^® are currently available as Version 1.2024.

 

 

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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