Evaluating implementation of NCCN guideline-directed genetic screening recommendations for patients with pancreatic ductal adenocarcinoma

PURPOSE

In 2019, the National Comprehensive Cancer Network (NCCN) recommended genetic testing for all patients with pancreatic ductal adenocarcinoma (PDAC). To evaluate the status of implementation of these guidelines in a loco-regional setting, we performed a retrospective, observational study among patients with newly diagnosed PDAC who received oncologic care at Northeast Georgia Medical Center in Georgia.

METHODS

Chart abstraction of patients with newly diagnosed PDAC from 1 January 2020 to 31 December 2021 was performed to include information on genetic testing recommendation and completion, and time from diagnosis to testing. The deidentified dataset was then analyzed using appropriate descriptive and associative statistical testing.

RESULTS

Of the cohort of 109 patients, 32 (29.4%) completed genetic screening; 16 (14.7%) were screened within 10 days of diagnosis. Among the 77 (70.6%) patients who did not receive genetic screening, 45 (41.3%) were not recommended genetic screening despite treatment intent with standard of care therapy. However, 32 (29.4%) were not recommended genetic screening in conjunction with a desire to pursue palliative care/hospice/or due to terminal illness.

CONCLUSIONS

The study highlighted the gap in implementation of NCCN guideline-directed genetic testing in PDAC patients as only a third underwent testing suggesting the need for systematic processes to facilitate testing. The test was more likely to be completed if done early in the course, especially soon after the diagnosis. Research is needed to explore discussing genetic testing for the large proportion of patients who are terminally ill at diagnosis where genetic screening would potentially benefit the family members.

Quarter Century Positron Emission Tomography/Computed Tomography Transformation of Oncology: Head and Neck Cancer

During the last 2 decades, f-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F FDG PET/CT) has transformed the clinical head and neck cancer imaging for patient management and predicting survival outcomes. It is now widely used for staging, radiotherapy planning, posttherapy assessment, and for detecting recurrence in head and neck cancers and is widely included in NCCN and other evidence based clinical practice guidelines. Future Directions would include evaluating the potential value of FAPI PET/CT for head and neck cancers, opportunity to use volumetric and tumor heterogeneity parameters and deploying AI in diagnostic and therapeutic assessments.

NCCN Guideline Concordance Improves Survival in Pediatric and Young Adult Rectal Cancer

BACKGROUND

Although management guidelines in adult rectal cancer are widely studied, no consensus guidelines exist for the management of pediatric and young adult rectal cancer.

METHODS

The National Cancer Database (2004-2018) was queried for pediatric (age 0-21) and young adult (age 22-40) patients with rectal cancer. Patients were analyzed for receipt of National Comprehensive Cancer Network (NCCN) guideline-concordant therapy. Impact on survival was evaluated using Cox regression and Kaplan-Meier analysis.

RESULTS

6655 patients (108 pediatric and 6547 young adult patients) with rectal cancer were included. Similar to previously published NCCN quality measures with overall guideline concordance approaching 90 % in adults, 89.6 % of pediatric and 84.6 % of young adult patients were classified as receiving pre-operative guideline-concordant therapy. However, pediatric patients were significantly less likely to receive post-operative guideline-concordant therapy than young adult patients (65.3 % verse 76.7 %, respectively, p = 0.008). Risk of death was significantly lower for pediatric patients who received post-operative guideline-concordant therapy (HR, 0.313; CI, 0.168-0.581; p < 0.001). In young adult patients, risk of death was significantly lower for those who received pre-operative guideline-concordant therapy (HR, 0.376, CI 0.338-0.417, p < 0.001), and post-operative guideline-concordant therapy (HR, 0.456; CI 0.413-0.505; p < 0.001).

DISCUSSION

NCCN-based guidelines may reasonably guide peri-operative management decisions and improve survival in pediatric and young adult rectal cancer. Given the rarity of this cancer in young patients, employment of an experienced surgical and oncologic multidisciplinary team, along with discussion and involvement of the patient and family, are keys for balancing risks and benefits to offering the best therapeutic strategy.

TYPE OF STUDY

Retrospective.

LEVEL OF EVIDENCE

Level III.

The impact of NCCN-compliant multidisciplinary conference on the uptake of active surveillance among eligible patients with localized prostate cancer

INTRODUCTION

We sought to investigate the impact of National Comprehensive Cancer Network (NCCN)-compliant multidisciplinary conference on the uptake of active surveillance (AS) among eligible patients with prostate cancer.

METHODS

Retrospective review of our AS database was performed. Patients who are eligible for AS who sought a second opinion at a comprehensive cancer center (2010-2021) were presented to the multidisciplinary Localized Prostate Cancer Conference (LPCC) that includes urologists, radiation oncologists, pathologists, and patient advocates. Cochrane Armitage test was used to examine trends over time. Multivariable regression models were fit to evaluate variables associated with the receipt of AS.

RESULTS

Seven hundred twelve patients were identified (19% NCCN very low risk, 32% low risk, and 49% intermediate favorable risk). 43% were recommended AS as the preferred option by the community compared to 68% by LPCC, and 65% elected AS. Recommending AS significantly increased between 2010 and 2021 by the community (from 26% to 57%) and by LPCC (from 52% to 82%), while the proportion of men who received AS increased from 47% to 80% during the same period (P < 0.0001 for all). More recent LPCC era 2017 to 2021 (OR 12.31, 95% CI, 5.60-27.03, P < 0.0001), African American race (OR 0.42, 95% CI, 0.18-0.96, P = 0.04), positive cores at biopsy (OR 0.96, 95% CI, 0.94-0.97, P < 0.0001), age (OR 1.14, 95% CI, 1.10-1.18, P < 0.0001), NCCN low risk (OR 0.25, 95% CI, 0.08-0.81, P = 0.02) and NCCN intermediate favorable risk (OR 0.03, 95% CI, 0.01-0.09, P < 0.0001) were associated with receipt of AS.

CONCLUSION

AS recommendation increased significantly over time by community urologists and to a higher extent by NCCN-compliant multidisciplinary conference. The Uptake of AS significantly increased within the same period. More recent LPCC era 2017 to 2021, African American race, the proportion of positive cores at biopsy, age, and NCCN risk were the main determinants of receipt of AS.

Disparities in Receipt of National Comprehensive Cancer Network Guideline-Adherent Care and Outcomes among Women with Triple-Negative Breast Cancer by Race/Ethnicity, Socioeconomic Status, and Insurance Type

BACKGROUND

The National Comprehensive Cancer Network guidelines were designed to improve patient outcomes. Here, we examine factors that may contribute to outcomes and guideline adherence in patients with triple-negative breast cancer.

METHODS

This was a retrospective cohort study of women with triple-negative breast cancer using the California Cancer Registry. Adherent treatment was defined as the receipt of a combination of surgery, lymph node assessment, adjuvant radiation, and/or chemotherapy. A multivariable logistic regression was used to determine the effects of independent variables on adherence to the NCCN guidelines. Disease-specific survival was calculated using Cox regression analysis.

RESULTS

A total of 16,858 women were analyzed. Black and Hispanic patients were less likely to receive guideline-adherent care (OR 0.82, 95%CI 0.73-0.92 and OR 0.87, 95%CI 0.79-0.95, respectively) compared to White patients. Hazard ratios adjusted for adherent care showed that Black patients had increased disease-specific mortality (HR 1.28, 95%CI 1.16-1.42, p < 0.0001) compared to White patients.

CONCLUSIONS

A significant majority of breast cancer patients in California continue to receive non-guideline-adherent care. Non-Hispanic Black patients and patients from lower SES quintile groups were less likely to receive guideline-adherent care. Patients with non-adherent care had worse disease-specific survival compared to recipients of NCCN guideline-adherent care.

Surgical and Endoscopic Resection of Duodenal Neuroendocrine Tumors Have Similar Disease-Specific Survival Outcome

BACKGROUND

Duodenal neuroendocrine tumors (dNETs) are rare, and their management is not well-defined. National Comprehensive Cancer Network (NCCN) guidelines recommend surgical resection of large dNETs (> 2 cm) and endoscopic resection of small tumors (< 2 cm). We compared the survival outcomes between surgical and endoscopic resection in various dNET sizes.

METHODS

A retrospective cohort study was conducted using patient data from Surveillance, Epidemiology, and End Results Program (SEER) database. Variables analyzed included age, tumor size, grade, stage, and lymph node status. Disease-specific survival (DSS) was compared for endoscopic and surgical groups in dNET size strata: 0-0.5, 0.5-1, 1-2, 2-3, and > 3 cm. Kaplan-Meier and multivariable Cox proportional hazards models were used for survival analysis.

RESULTS

The study included 465 patients, with 124 (26.7%) undergoing surgical resection. The average age was 61.9 years, and tumor sizes ranged from 0.1 to 10.5 cm. Endoscopic resection had 40.5% of tumors between 0 and 0.5 cm, while surgery had only 21% (p < 0.001). In the surgical cohort, 79.8% had grade 1 tumors compared to 88.3% in the endoscopy group (P = 0.024). Among surgically resected cases, 48.4% (60 patients) had lymph node involvement. Age, tumor size, grade, and stage did not significantly predict survival after surgical resection. Stratified by tumor size, no difference in DSS was observed between surgery and endoscopy groups.

CONCLUSIONS

Endoscopic resection demonstrated similar survival outcomes to surgical resection across dNET sizes in this national analysis. Given the risks and the lack of survival benefits for surgery, endoscopic resection may be beneficial for both small and large tumors. Further studies are warranted to validate the current NCCN guidelines.

Persistent race- and sex-based disparities in lung cancer screening eligibility

OBJECTIVE

To evaluate race- and sex-based disparities in lung cancer screening eligibility under the 2013 US Preventive Services Task Force, 2021 US Preventive Services Task Force, and National Comprehensive Cancer Network lung cancer screening guidelines.

METHODS

Participants in the Southern Community Cohort Study with a smoking history diagnosed with lung cancer from 2002 to 2021 were identified for analysis. Differences in age at lung cancer diagnosis and smoking characteristics were evaluated among 4 groups: Black men, Black women, White men, and White women.

RESULTS

A total of 2011 patients with lung cancer met study inclusion criteria, of whom 968 (48.1%) were women and 1248 (62.1%) were Black. Under the 2013 guideline, Black men with lung cancer were significantly less likely to be eligible for screening when compared with White men with lung cancer (37.7% vs 62.4%; P < .001), and Black women with lung cancer were significantly less likely to be eligible for screening when compared with White women with lung cancer (27.8% vs 56.7%; P < .001). Under the 2021 guideline, 62.6% of Black and 73.8% of White men (P < .001) with lung cancer would have been eligible for screening, resulting in an 11.2 percentage point difference in screening eligibility between Black and White men. Under the 2021 guideline, 50.3% of Black and 74.9% of White (P < .001) women with lung cancer would have been eligible for screening; notably, there remained a 24.6 percentage point difference in screening eligibility between Black and White women. In multivariable-adjusted analysis, under the 2021 USPSTF guideline, Black men with lung cancer had 46% lower odds of being eligible for screening compared with White men with lung cancer (multivariable-adjusted odds ratio [aOR], 0.54; 95% CI, 0.39-0.76; P < .001) and Black women with lung cancer had 66% lower odds of being eligible for screening compared with White women with lung cancer (aOR, 0.34; 95% CI, 0.25-0.46; P < .001). The National Comprehensive Cancer Network guideline increased the proportion of patients with lung cancer eligible for screening in each group.

CONCLUSIONS

In this analysis of patients with lung cancer in the Southern Community Cohort Study, there remained a large gap in lung cancer screening eligibility between Black and White men and women under the 2021 US Preventive Services Task Force guideline. Only 50% of Black women and 63% of Black men diagnosed with lung cancer would have qualified for screening.

Effect on Germline Mutation Rate in a High-Risk Chinese Breast Cancer Cohort after Compliance with The National Comprehensive Cancer Network (NCCN) 2023 v.1 Testing Criteria

BACKGROUND

The National Comprehensive Cancer Network (NCCN) testing criteria for the high-penetrance breast cancer susceptibility genes, specifically BRCA1, BRCA2, CDH1, PALB2, PTEN, and TP53, have been recently modified in 2023 to 2023 v.1. The following criteria have been changed: (1) from a person diagnosed with breast cancer at ≤45 to ≤50; (2) from aged 45-50 of personal breast diagnosis to any age of diagnosis with multiple breast cancers; and (3) from aged ≥51 of personal breast diagnosis to any age of diagnosis with family history listed in NCCN 2022 v.2.

METHODS

High-risk breast cancer patients (n = 3797) were recruited from the Hong Kong Hereditary Breast Cancer Family Registry between 2007 and 2022. Patients were grouped according to NCCN testing criteria 2023 v.1 and 2022 v.2. A 30-gene panel for hereditary breast cancer was performed. The mutation rates on high-penetrance breast cancer susceptibility genes were compared.

RESULTS

About 91.2% of the patients met the 2022 v.2 criteria, while 97.5% of the patients met the 2023 v.1 criteria. An extra 6.4% of the patients were included after the revision of the criteria, and 2.5% of the patients did not meet both testing criteria. The germline BRCA1/2 mutation rates for patients meeting the 2022 v.2 and 2023 v.1 criteria were 10.1% and 9.6%, respectively. The germline mutation rates of all 6 high-penetrance genes in these two groups were 12.2% and 11.6%, respectively. Among the additional 242 patients who were included using the new selection criteria, the mutation rates were 2.1% and 2.5% for BRCA1/2 and all 6 high-penetrance genes, respectively. Patients who did not meet both testing criteria were those with multiple personal cancers, a strong family history of cancers not listed in the NCCN, unclear pathology information, or the patient's voluntary intention to be tested. The mutation rates of BRCA1/2 and the 6 high-penetrance genes in these patients were 5.3% and 6.4%, respectively.

CONCLUSION

This study provided a real-world application of the revision of NCCN guidelines and its effect on the germline mutation rate in the Chinese population. Applying the updated criteria for further genetic investigation would increase the positive detection rate, and potentially more patients would benefit. The balance between the resource and outcome requires careful consideration.

Impact of an NCCN-Compliant Multidisciplinary Conference on Treatment Decisions for Localized Prostate Cancer

BACKGROUND

We sought to investigate the impact of an NCCN-compliant multidisciplinary conference on treatment decisions of patients with localized prostate cancer.

METHODS

A retrospective review of our quality assurance localized prostate cancer database was performed. All patients with localized prostate cancer who sought a second opinion at Roswell Park Comprehensive Cancer Center between 2009 and 2019 were presented to the multidisciplinary Localized Prostate Cancer Conference (LPCC) that includes urologists, radiation oncologists, pathologists, and patient advocates. Multivariable regression models were fit to evaluate variables associated with concordance between community recommendations, LPCC recommendations, and treatment received by patients.

RESULTS

A total of 1,164 patients were identified, of whom 26% had NCCN very low-/low-risk, 27% had favorable intermediate-risk, 25% had unfavorable intermediate-risk, and 22% had high-/very high-risk prostate cancer. Pathology changed in 11% of patients after genitourinary pathologist review, which caused disease reclassification in 9%. Concordance between community and LPCC recommendations occurred in 78%, with lowest concordance for androgen deprivation therapy (21%) and radiotherapy (53%). Concordance between community recommendations and treatment received occurred in 65%, with lowest concordance for androgen deprivation therapy and radiotherapy; among those who were recommended radiotherapy as the only option by their community urologist, only 26% received it. Concordance between LPCC recommendations and treatment received occurred in 92%.

CONCLUSIONS

Community recommendations differed from the multidisciplinary NCCN-compliant recommendations in 22% of patients, primarily for radiotherapy. Multidisciplinary recommendations matched the treatment received in 92% of patients compared with 65% for community recommendations.

The 31-gene expression profile test informs sentinel lymph node biopsy decisions in patients with cutaneous melanoma: results of a prospective, multicenter study

BACKGROUND

The 31-gene expression profile test (Class 1A: low-risk; 1B/2A: intermediate-risk; 2B: high-risk) is validated to identify patients with cutaneous melanoma who can safely forego sentinel lymph node biopsy (SLNB). The objective of the current study is to quantify SLNB reduction by clinicians using 31-GEP.

METHODS

Patients with T1-T2 tumors eligible for SLNB were seen by surgical oncologists (89.1%), dermatologists (7.8%), and medical oncologists (3.1%). After receiving 31-GEP results but before SLNB, clinicians were asked which clinical and pathological features influenced SLNB decisions (n = 191). The Exact binomial test was used to compare SLNB procedure rates to a contemporary study (78% SLNB baseline rate). Logistic regression modeling (odds ratio [OR], 95% CI) was used to identify features associated with SLNB procedure rates.

RESULTS

One hundred clinical decisions (52.4%) were influenced by the 31-GEP to forego SLNB and 70% (70/100) were not performed. Of the 30 performed, 0% (0/30) were positive. The 31-GEP influenced sixty-three clinical decisions (33.0%) to perform SLNB, and 92.1% (58/63) were performed. There was a clinically meaningful 29.4% reduction of SLNBs performed in patients with a Class 1A result relative to the baseline rate of 78.0% (p < .01). In patients ≥55 or ≥65-year-old, SLNB reduction was 32.3% (p < .01), 28.3% (p < .01), respectively. Overall, 85.3% of decisions relating to SLNB were influenced by 31-GEP results.

CONCLUSION

In this prospective, multicenter study, clinicians demonstrated clinically meaningful use of the 31-GEP test to forego or pursue SLNB in patients with T1-T2 tumors resulting in a significant, risk appropriate decrease in SLNBs.

Vascular Invasion Predicts Recurrence in Stage IA2-IB Lung Adenocarcinoma but not Squamous Cell Carcinoma

BACKGROUND

Lymphovascular invasion (LVI) is an adverse prognostic feature in resected stage I non-small cell lung cancer (NSCLC); however, it is unclear if the prognostic significance applies to both lung adenocarcinoma (LUAD) and squamous cell carcinoma (LUSC).

MATERIALS AND METHODS

A retrospective review of H&E-stained slides from surgically resected AJCC 8^th ed. stage IA2-IB LUAD (n = 344) and LUSC (n = 102) from two institutions was performed. LVI was defined as either lymphatic (LI) or vascular (VI) invasion. Outcomes were assessed by 5-year recurrence-free survival (RFS) estimates using the Kaplan-Meier method.

RESULTS

The cohorts of LUAD and LUSC showed no significant differences in 5-year RFS (81% each), stage, age, race, or surgical procedure. The presence of LVI, VI, and LI was predictive of 5-year RFS for LUAD (LVI + 71% vs. LVI - 92%, P < 0.001; VI + 64% vs. VI - 90%, P < 0.001; LI + 75% vs. LI - 84%, P = 0.030) but not LUSC (LVI + 84% vs. LVI - 79%, P = 0.740; VI + 83% vs. VI- 80%, P = 0.852; LI + 84% vs. LI - 81%, P = 0.757). Among LUAD with LVI, VI was a stronger predictor of 5-year RFS than the remaining subset of VI-LI + tumors (64% vs. 87%, P = 004). Subset analysis of LI among LUAD stratified by VI showed no significant prognostic advantage to adding LI for risk stratification (VI-LI + 87% vs. VI-LI - 92%, P = 0.347 & VI+LI + 62% vs. VI + LI- 66%, P = 0.422). VI was present in 36% of LUAD.

CONCLUSION

Vascular invasion is a strong predictor of recurrence in stage IA2-IB LUAD but not in LUSC. Adjuvant therapy trials should be directed at this subgroup.

Evaluation of family history in individuals with heterozygous BRCA pathogenic variants diagnosed with breast or ovarian cancer in a single center in Italy

BACKGROUND

BRCA1 and BRCA2 gene mutations are responsible for 5% of breast cancer (BC) and 10-15% of ovarian cancer (EOC). The presence of a germline mutation and therefore the identification of subjects at high risk of developing cancer should ideally precede the onset of the disease, so that appropriate surveillance and risk-reducing treatments can be proposed. In this study, we revisited the family history (FH) of women who tested positive for BRCA mutations after being diagnosed with BC or EOC.

METHODS

The National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology (NCCN Guidelines®), and the Italian Association of Medical Oncology (AIOM) guidelines were applied to the FH of 157 women who were referred to San Gerardo Hospital for genetic counseling.

RESULTS

Almost 85% of women had an FH of BRCA-related cancer. 63.7% and 52.2% of women could have undergone genetic testing according to NCCN and AIOM testing criteria (p < .05) before tumor diagnosis. An FH of EOC was the most frequent NCCN criterion, followed by BC diagnosed <45 years old. Sixty-five percent of deceased women could have undergone genetic testing before developing cancer.

CONCLUSIONS

FH is a powerful tool to identify high-risk individuals eligible for genetic counseling and testing. Testing of healthy individuals should be considered when an appropriately affected family member is unavailable for testing.

Optimizing treatment approaches for patients with cutaneous melanoma by integrating clinical and pathologic features with the 31-gene expression profile test

BACKGROUND

Many patients with low-stage cutaneous melanoma will experience tumor recurrence, metastasis, or death, and many higher staged patients will not.

OBJECTIVE

To develop an algorithm by integrating the 31-gene expression profile test with clinicopathologic data for an optimized, personalized risk of recurrence (integrated 31 risk of recurrence [i31-ROR]) or death and use i31-ROR in conjunction with a previously validated algorithm for precise sentinel lymph node positivity risk estimates (i31-SLNB) for optimized treatment plan decisions.

METHODS

Cox regression models for ROR were developed (n = 1581) and independently validated (n = 523) on a cohort with stage I-III melanoma. Using National Comprehensive Cancer Network cut points, i31-ROR performance was evaluated using the midpoint survival rates between patients with stage IIA and stage IIB disease as a risk threshold.

RESULTS

Patients with a low-risk i31-ROR result had significantly higher 5-year recurrence-free survival (91% vs 45%, P < .001), distant metastasis-free survival (95% vs 53%, P < .001), and melanoma-specific survival (98% vs 73%, P < .001) than patients with a high-risk i31-ROR result. A combined i31-SLNB/ROR analysis identified 44% of patients who could forego sentinel lymph node biopsy while maintaining high survival rates (>98%) or were restratified as being at a higher or lower risk of recurrence or death.

LIMITATIONS

Multicenter, retrospective study.

CONCLUSION

Integrating clinicopathologic features with the 31-GEP optimizes patient risk stratification compared to clinicopathologic features alone.

Factors influencing quality of lymphadenectomy in minimally invasive esophagectomy: a US-based analysis

NCCN guidelines suggest that at least 15 lymph nodes (LN) should be evaluated at the time of esophagectomy to consider the lymphadenectomy 'adequate'. Despite these guidelines, this may not always be achieved in practice. The purpose of this study was to determine factors associated with adequate lymphadenectomy among patients receiving minimally invasive esophagectomy (MIE). Patients receiving MIE in the National Cancer Database from 2010 to 2016 were identified. Patients with metastatic disease were excluded. The primary endpoint was adequate lymphadenectomy, defined as >15 or greater LN evaluated. Factors associated with adequate lymphadenectomy and overall survival were evaluated in univariable and multivariable analyses. Categorical variables were assessed using chi-squared, and continuous variables were assessed with rank-sum test. Survival was evaluated using the Kaplan-Meier method. A total of 6,539 patients underwent MIE between 2010 and 2016 (5,024 thoracoscopic-laparoscopic MIE and 1,515 robotic-assisted MIE). A total of 3,527 patients (53.9%) received adequate lymphadenectomy. Receiving MIE at an academic center (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.15-1.63, P < 0.001), institutional volume of MIE (OR 1.01, 95% CI 1.008-1.011, P < 0.001), and presence of clinical nodal disease (OR 1.17, 95%CI 1.02-1.33, P = 0.025) were associated with adequate lymphadenectomy. Patients with >15 LN removed had increased overall survival (46.6 vs. 41.5 months, P < 0.001). Adequate lymphadenectomy (hazard ratio [HR] 0.77, 95%CI 0.71-0.85, P < 0.001), receiving surgery at an academic center (HR 0.87, 95%CI 0.78-0.96, P = 0.007) and private insurance status (HR 0.88, 95%CI 0.81-0.98, P = 0.02) were independently associated with improved survival. Nearly half of patients receiving MIE do not receive adequate lymphadenectomy as defined by NCCN guidelines. Receiving MIE at an academic center with high procedural volume and the presence of nodal disease were independently associated with adequate lymphadenectomy. Adequate lymphadenectomy was associated with improved survival. These findings suggest that providers performing esophagectomy should follow guideline-based recommendations for lymphadenectomy.

Rates of metastatic prostate cancer in newly diagnosed patients: Numbers needed to image according to risk level

BACKGROUND

The numbers needed to image to identify pelvic lymph node and/or distant metastases in newly diagnosed prostate cancer (PCa) patients according to risk level are unknown.

METHODS

Relying on Surveillance, Epidemiology, and End Results (2010-2016), we tabulated rates and proportions of patients with (a) lymph node or (b) distant metastases according to National Comprehensive Cancer Network (NCCN) risk level and calculated the number needed to image (NNI) for both endpoints. Multivariable logistic regression analyses were performed.

RESULTS

Of 145,939 newly diagnosed PCa patients assessable for analyses of pelvic lymph node metastases (cN1), 4559 (3.1%) harbored cN1 stage: 13 (0.02%), 18 (0.08%), 63 (0.3%), 512 (2.8%), and 3954 (14.9%) in low, intermediate favorable, intermediate unfavorable, high, and very high-risk levels. These resulted in NNI of 4619, 1182, 319, 35, and 7, respectively. Of 181,109 newly diagnosed PCa patients assessable for analyses of distant metastases (M1_a-c ), 8920 (4.9%) harbored M1_a-c stage: 50 (0.07%), 45 (0.1%), 161 (0.5%), 1290 (5.1%), and 7374 (22.0%) in low, intermediate favorable, intermediate unfavorable, high, and very high-risk. These resulted in NNI of 1347, 602, 174, 20, and 5, respectively.

CONCLUSIONS

Our observations perfectly validated the NCCN recommendations for imaging in newly diagnosed high and very high-risk PCa patients. However, in unfavorable intermediate-risk PCa patients, in whom bone and soft tissue imaging is recommended, the NNI might be somewhat elevated to support routine imaging in clinical practice.

Impact of NCCN Guideline Adherence in Adult Cancer Pain on Length of Stay

To improve the management of cancer related pain, the National Comprehensive Cancer Network (NCCN) publishes the Adult Cancer Pain guideline on an annual basis. However, a large majority of oncology patients still report inadequate pain control. Single-center, retrospective cohort study of adult patients admitted for uncontrolled pain or pain crisis between 3/1/19 and 06/30/20 were assigned to cohorts of either adherent or non-adherent to NCCN guideline recommendations for management of pain crises based on their initial opioid orders. Patients must have reported a pain score >/= 4 and received at least one dose of opioids within 24 hours upon admission. The length of stay (LOS), pain scores, and naloxone administration were compared between both groups. Patients in the adherent group had a shorter median LOS (3.7 days [range: 1 to 18.93] vs 5.4 days [range: 1.45 to 19.64 days], p = 0.04). Patients that received lower doses than recommended had longer LOS compared to adherent group (6.1 vs. 3.7 days; p = 0.009). When adjusted for confounders, this significance did not remain. The lowest reported pain score within 24 hours of admission was lower in the adherent group (median 3 vs 4, p = 0.04). Predictors of LOS included opioid tolerance and a pain or palliative care consult. Adherence to NCCN guidelines for acute pain crisis management in adult patients with cancer remains poor. Patients who received guideline adherent initial opioid regimens demonstrated a trend toward a shorter LOS. Opioid-tolerant patient outcomes remain inadequate; appropriate pain management for these patients need to improve.

Efficacy of Clinical Guidelines in Identifying All Japanese Patients with Hereditary Breast and Ovarian Cancer

Clinical screening using the National Comprehensive Cancer Network (NCCN) testing criteria may fail to identify all patients with hereditary breast and ovarian cancers. Thus, this study aimed to evaluate the strategy of expanding target patients for genetic testing among Japanese patients. We reviewed the medical records of 91 breast cancer patients who underwent genetic testing. Among 91 patients, eight were diagnosed with pathogenic or likely pathogenic variants: BRCA1 (n = 4) and BRCA2 (n = 4). Among 50 patients meeting the testing criteria of the guidelines, 6 (12%) were diagnosed with pathogenic or likely pathogenic variants. The sensitivity and specificity of screening using the testing criteria were 75% and 47%, respectively. Expanding the NCCN criteria to include all women diagnosed with breast cancer aged ≤65 years achieved 88% sensitivity but 8% specificity. The expansion of the NCCN criteria could benefit Japanese patients; however, larger studies are necessary to change clinical practice.

Guideline - Adherence in advanced stage head and neck cancer is associated with improved survival - A National study

OBJECTIVES

Understanding the prevalence of guideline non-adherence among patients with advanced head and neck cancer (HNC) and its impact on survival may facilitate increased adherence. Our objective was to perform a detailed analysis of overall National Comprehensive Care Network (NCCN) guideline adherence in a national cohort.

METHODS

Using the National Cancer Database, we analyzed site-specific NCCN guideline adherence for treatment of 100,074 overall stage III and IVA HNC patients from 2004 to 2013. Main outcomes were guideline adherence rates and overall survival (OS). Adherence was categorized by treatment: surgery/ radiation. Reasons were categorized as: (1) high risk; (2) refusal; (3) not planned.

RESULTS

After exclusion, the care of 25,620 patients was defined as non-adherent (25.6%), yet adherence rates significantly improved across the study's years. After multivariate analysis, non-adherence was associated with age ≥ 65, female gender, black race, comorbidity score ≥ 1, insurance status, clinical staging, primary site, and facility type. Patients not managed according to NCCN guidelines had a significantly reduced OS compared with patients treated on-guideline (hazard ratio (HR) = 1.51 (95 %CI 1.48-1.54), p < 0.001). 'Not planned' patients had reduced OS when compared to adherent patients (HR = 1.27 (95 %CI 1.23-1.30), p < 0.001). Off-guideline treated patients due to 'risk factors' had a decrease in overall survival (OS) compared with other reasons (p < 0.001 for all).

CONCLUSIONS

Despite improvement over time, non-adherence to NCCN guidelines for advanced stage HNC remains high. Non-adherence is associated with decreased OS, regardless of the reason. Despite concerns from both patient and physician, efforts should be made to increase guideline awareness and adherence.

Assessment of the optimal number of positive biopsy cores to discriminate between cancer-specific mortality in high-risk versus very high-risk prostate cancer patients

BACKGROUND

Number of positive prostate biopsy cores represents a key determinant between high versus very high-risk prostate cancer (PCa). We performed a critical appraisal of the association between the number of positive prostate biopsy cores and CSM in high versus very high-risk PCa.

METHODS

Within Surveillance, Epidemiology, and End Results database (2010-2016), 13,836 high versus 20,359 very high-risk PCa patients were identified. Discrimination according to 11 different positive prostate biopsy core cut-offs (≥2-≥12) were tested in Kaplan-Meier, cumulative incidence, and multivariable Cox and competing risks regression models.

RESULTS

Among 11 tested positive prostate biopsy core cut-offs, more than or equal to 8 (high-risk vs. very high-risk: n = 18,986 vs. n = 15,209, median prostate-specific antigen [PSA]: 10.6 vs. 16.8 ng/ml, <.001) yielded optimal discrimination and was closely followed by the established more than or equal to 5 cut-off (high-risk vs. very high-risk: n = 13,836 vs. n = 20,359, median PSA: 16.5 vs. 11.1 ng/ml, p < .001). Stratification according to more than or equal to 8 positive prostate biopsy cores resulted in CSM rates of 4.1 versus 14.2% (delta: 10.1%, multivariable hazard ratio: 2.2, p < .001) and stratification according to more than or equal to 5 positive prostate biopsy cores with CSM rates of 3.7 versus 11.9% (delta: 8.2%, multivariable hazard ratio: 2.0, p < .001) in respectively high versus very high-risk PCa.

CONCLUSIONS

The more than or equal to 8 positive prostate biopsy cores cutoff yielded optimal results. It was very closely followed by more than or equal to 5 positive prostate biopsy cores. In consequence, virtually the same endorsement may be made for either cutoff. However, more than or equal to 5 positive prostate biopsy cores cutoff, based on its existing wide implementation, might represent the optimal choice.

Increasing rates of NCCN high and very high-risk prostate cancer versus number of prostate biopsy cores

BACKGROUND

Recently, an increase in the rates of high-risk prostate cancer (PCa) was reported. We tested whether the rates of and low, intermediate, high and very high-risk PCa changed over time. We also tested whether the number of prostate biopsy cores contributed to changes rates over time.

METHODS

Within the Surveillance, Epidemiology and End Results (SEER) database (2010-2015), annual rates of low, intermediate, high-risk according to traditional National Comprehensive Cancer Network (NCCN) and high versus very high-risk PCa according to Johns Hopkins classification were tabulated without and with adjustment for the number of prostate biopsy cores.

RESULTS

In 119,574 eligible prostate cancer patients, the rates of NCCN low, intermediate, and high-risk PCa were, respectively, 29.7%, 47.8%, and 22.5%. Of high-risk patients, 39.6% and 60.4% fulfilled high and very high-risk criteria. Without adjustment for number of prostate biopsy cores, the estimated annual percentage changes (EAPC) for low, intermediate, high and very high-risk were respectively -5.5% (32.4%-24.9%, p < .01), +0.5% (47.6%-48.4%, p = .09), +4.1% (8.2%-9.9%, p < .01), and +8.9% (11.8%-16.9%, p < .01), between 2010 and 2015. After adjustment for number of prostate biopsy cores, differences in rates over time disappeared and ranged from 29.8%-29.7% for low risk, 47.9%-47.9% for intermediate risk, 8.9%-9.0% for high-risk, and 13.6%-13.6% for very high-risk PCa (all p > .05).

CONCLUSIONS

The rates of high and very high-risk PCa are strongly associated with the number of prostate biopsy cores, that in turn may be driven by broader use magnetic resonance imaging (MRI).

Optimizing External Beam Radiotherapy as per the Risk Group of Localized Prostate Cancer: A Nationwide Multi-Institutional Study (KROG 18-15)

Simple Summary

This multi-institutional study analyzed the patterns of care and outcomes of external beam radiotherapy (EBRT) in localized prostate cancer to identify the optimal EBRT strategy for each risk-stratified patient subgroup for clinical practice implementation. In 1573 patients from 17 institutions, EBRT treated prostate cancer effectively. Also, among various risk classification tools, NCCN classification revealed the highest predictive power. The modern RT techniques and dose escalation (≥179 Gy_1.5) enhanced therapeutic effects of RT significantly, especially in the high-risk group. On the other hand, modest doses (≥170 Gy_1.5) was a significant factor in the intermediate-risk group and no significant impact of dose was observed in the low-risk group. IMRT+ ≥179 Gy_1.5+ hypofractionation resulted in higher biochemical failure-free survival in all risk groups, and it translated into survival benefits in the high-risk group. Therefore, risk-adapted RT (more intense RT, high-risk patients; moderate-dose RT, low-risk patients) can be considered, although further prospective studies are warranted.

Abstract

Purpose: This nationwide multi-institutional study analyzed the patterns of care and outcomes of external beam radiotherapy (EBRT) in localized prostate cancer patients. We compared various risk classification tools and assessed the need for refinements in current radiotherapy (RT) schemes. Methods and Materials: We included non-metastatic prostate cancer patients treated with primary EBRT from 2001 to 2015 in this study. Data of 1573 patients from 17 institutions were analyzed and re-grouped using a risk stratification tool with the highest predictive power for biochemical failure-free survival (BCFFS). We evaluated BCFFS, overall survival (OS), and toxicity rates. Results: With a median follow-up of 75 months, 5- and 10-year BCFFS rates were 82% and 60%, and 5- and 10-year OS rates were 95% and 83%, respectively. NCCN risk classification revealed the highest predictive power (AUC = 0.556, 95% CI 0.524–0.588; p < 0.001). Gleason score, iPSA < 12 ng/mL, intensity-modulated RT (IMRT), and ≥179 Gy_1.5 (EQD2, 77 Gy) were independently significant for BCFFS (all p < 0.05). IMRT and ≥179 Gy_1.5 were significant factors in the high-risk group, whereas ≥170 Gy_1.5 (EQD2, 72 Gy) was significant in the intermediate-risk group and no significant impact of dose was observed in the low-risk group. Both BCFFS and OS improved significantly when ≥179 Gy_1.5 was delivered using IMRT and hypofractionation in the high-risk group without increasing toxicities. Conclusions: With NCCN risk classification, dose escalation with modern high-precision techniques might increase survivals in the high-risk group, but not in the low-risk group, although mature results of prospective studies are awaited.

Is pelvic MRI imaging sufficient cross-sectional imaging for staging intermediate and high-risk prostate cancer?

OBJECTIVES

The American Urological Association's (AUA) and National Comprehensive Cancer Network's (NCCN) provide highly recognized guidelines for staging prostate cancer (CaP). However, both are vague as to specific type of cross-sectional imaging (CT vs. MRI) and extent (abdominal vs. pelvis), thereby raising concern for overlapping imaging. We investigated if current AUA and NCCN CaP staging guidelines can become more specific yet maintain sufficient staging.

METHODS

We identified 493 patients diagnosed with CaP between 2011 and 2017 and focused analysis on those with AUA and NCCN Intermediate risk (IR) and High risk (HR) groups. Type of staging imaging was recorded and frequency of overlapping (CT + MRI) and abdominal imaging determined. Significance of radiologist findings, for both overlapping and abdominal imaging, were classified as nonurologic, nonsignificant urologic, and CaP significant.

RESULTS

Among IR and HR AUA and NCCN risk groups, 82 (35.7%) and 95 (37.3%) patients, respectively, experienced overlapping imaging, of which only 7 patients in AUA and 9 patients in NCCN risk groups had an abnormal CT with normal MRI. However, only 3 of these CTs had CaP significant findings, of which 2 identified bone metastases, which were subsequently detected on bone scan. In regard to the extent of imaging, a total of 157 (68.2%) AUA and 178 (69.8%) NCCN IR and HR patients received abdominal scans, of which only 46 (20.0%) and 49 (19.2%) were abnormal among AUA and NCCN risk groups, respectively. Among these abnormal abdominal scans, only 10 showed CaP significant findings, of which half were suspected bone metastases, and confirmed on recommended bone scan.

CONCLUSIONS

Due to nonspecific staging guidelines in IR and HR CaP regarding type and extent of cross-sectional imaging, patients are frequently receiving imaging of overlapping locations. Based on low occurrences of unique CaP significant findings on CT and abdominal imaging, our exploratory analysis suggests that narrowing cross-sectional imaging recommendations to pelvic MRI may reduce imaging overlap while maintaining sufficient staging.

National comprehensive cancer network recommendations for drugs without US food and drug administration approval in metastatic breast cancer: A cross-sectional study

BACKGROUND

National Comprehensive Cancer Network (NCCN) guidelines can include recommendations for off-label use of anti-cancer drugs. Here, we evaluate NCCN recommendations not supported by US Food and Drug Administration (FDA) approval and explore associations with such recommendations.

METHODS

All NCCN recommendations for MBC and their supporting data were identified. Drug labels were reviewed to determine whether recommendations are FDA approved. Logistic regression was used to compare FDA approved and off-label recommendations for pre-specified categories, including drug type, tumor subtype, level of recommendation and line of therapy.

RESULTS

Of 124 recommendations identified, 68 (55%) were off-label. Chemotherapy and human epidermal growth factor receptor 2 (HER2) targeted drugs were associated with lower odds of FDA approval (OR = 0.28, p = 0.001 and OR = 0.29, 95% p = 0.005, respectively). Recommendations for endocrine therapy (OR = 3.44, p = 0.009) and non-HER2 targeted treatment (OR = 10.0, p < 0.001) were more commonly FDA approved indications. Compared to combination therapies, monotherapies were more likely to be FDA approved (OR = 3.45, p = 0.001) as were category 1 (OR = 7.63, p = 0.001) and preferred NCCN recommendations (OR = 4.07, p < 0.001). Compared to off-label recommendations, NCCN recommendations of approved drugs were based on significantly higher sample size (mean 477 vs. 342 patients, p = 0.02) and were non-significantly associated with availability of randomized data (OR = 2.0, 95% CI 0.89-4.49, p = 0.09).

CONCLUSION

More than half of all NCCN recommendations for MBC are off-label, mostly involving chemotherapy containing regimes for HER2 negative disease and combinations which include HER2-targeted drugs. Improved transparency of NCCN guidelines may result from reporting of the strength of the evidence supporting recommendations for MBC.

A Dermatologist's Guide to Implementation of Gene Expression Profiling in the Management of Melanoma

BACKGROUND. With the advent of effective therapeutics, melanoma mortality rates have decreased, yet incidence rates are continuing to rise, making accurate prognostication for risk of recurrence increasingly important. Gene expression profiling (GEP) is a clinically available, objective metric that can be used in conjunction with traditional clinicopathological staging to help physicians stratify risk in melanoma patients. There is a gap in guidance from the American Joint Committee on Cancer (AJCC) and the National Comprehensive Cancer Network (NCCN) regarding how to utilize GEP in melanoma care. OBJECTIVE. An expert panel of 31-GEP test users sought to provide clarification of use options and a rational clinical workflow to guide appropriate application of the 31- GEP test in everyday practice. METHODS. The authors participated in an in-depth review of the literature and panel discussion regarding current limitations of melanoma risk assessment and opportunities for improvement with GEP. The panel reviewed 1) validation and clinical impact data supporting the use of sentinel lymph node biopsy (SLNB), 2) existing primary data and meta-analyses for 31-GEP testing in melanoma risk assessment, 3) AJCC, NCCN, and Melanoma Prevention Working Group (MPWG) data and guidelines for GEP use in melanoma risk assessment, and 4) experiences, rationales, and scenarios in which 31-GEP testing may be helpful for risk assessment. RESULTS. The 31-GEP test is useful and actionable for patient care when applied in accordance with current NCCN guidelines. Stratification of patients into low (Class 1a), intermediate (Class 1b or 2a), or high (Class 2b) risk categories can inform multidisciplinary conference discussion and can assist with determining the intensity of imaging, surveillance, and follow-up care. Patient-specific features of the disease and individual circumstances should be considered in the decision to use 31-GEP testing. CONCLUSION. The authors suggest a clinical workflow that integrates 31-GEP testing under the umbrella of current national guidelines. Application of the test in appropriate patient populations can improve risk assessment and inform clinical decision-making.

Recurrence patterns in patients with Stage II melanoma: The evolving role of routine imaging for surveillance

BACKGROUND AND OBJECTIVES

The relatively recent availability of effective systemic therapies for metastatic melanoma necessitates reconsideration of current surveillance patterns. Evidence supporting surveillance guidelines for resected Stage II melanoma is lacking. Prior reports note routine imaging detects only 21% of recurrent disease. This study aims to define recurrence patterns for Stage II melanoma to inform future surveillance guidelines.

METHODS

This is a retrospective study of patients with Stage II melanoma. We analyzed risk factors for recurrence and methods of recurrence detection. We also assessed survival. Yearly hazards of recurrence were visualized.

RESULTS

With a median follow-up of 4.9 years, 158 per 580 patients (27.2%) recurred. Overall, most recurrences were patient-detected (60.7%) or imaging-detected (27.3%). Routine imaging was important in detecting recurrence in patients with distant recurrences (adjusted rate 43.1% vs. 9.4% for local/in-transit; p = .04) and with Stage IIC melanoma (42.5% vs. 18.5% for IIA; p = .01). Male patients also self-detected recurrent disease less than females (52.1% vs. 76.8%; p < .01).

CONCLUSIONS

Routine imaging surveillance played a larger role in detecting recurrent disease for select groups in this cohort than noted in prior studies. In an era of effective systemic therapy, routine imaging should be considered for detection of asymptomatic relapse for select, high-risk patient groups.

Category of evidence and consensus underlying National Comprehensive Cancer Network guidelines: Is there evidence of progress?

National Comprehensive Cancer Network (NCCN) guidelines are the most comprehensive and widely used standard for clinical care, financial reimbursements and quality improvement initiatives in oncology. We studied the distribution of categories of evidence and consensus (EC) in the guidelines for the common cancers in the United States. We evaluated the EC categories in staging, therapy and surveillance recommendations in 2019 guidelines and compared them with the same in 2010. The latest 2019 version of NCCN guidelines were obtained. The definitions for various categories of EC used were, Category 1 (high level evidence, uniform consensus), Category 2A (lower level of evidence [LOE], uniform consensus), Category 2B (lower LOE, no uniform consensus but with no major disagreement) and Category 3 (any LOE, major disagreement). We compared our results with previously published results from 2010 guidelines. Total number of recommendations increased by 77% from 1023 (2010) to 1818 (2019). Of the 1818 recommendations, Category 1, 2A, 2B and 3 EC were 7%, 87%, 6% and 0%, respectively, while in 2010 they were 6%, 83%, 10% and 1%. Breast (30%), lung (10%) and kidney (10%) cancer had the highest proportions of Category 1 therapeutic recommendations in their respective guidelines. No Category 1 recommendations were found in screening or surveillance guidelines or in pancreatic and uterine cancer guidelines. Recommendations in 2019 NCCN guidelines are largely Category 2A (lower levels of evidence, uniform expert opinion), unchanged from the previous study in 2010.

Radiotherapy of Prostate Carcinoma: A Comparison of the Predictive Role of EAU Versus NCCN Risk Stratification Systems

BACKGROUND/AIM

To compare the predictive efficacy of National Comprehensive Cancer Network (NCCN) and European Association of Urology (EAU) risk stratification systems in radiotherapy of prostate cancer.

PATIENTS AND METHODS

One-thousand-nine-hundred-nine patients treated with definitive (1,074), adjuvant (381), and salvage radiotherapy (454) were analysed.

RESULTS

Both systems significantly predicted biochemical-relapse-free-survival, metastasis-free-survival, and disease-free-survival, while only the NCCN system correlated with local-control in the definitive radiotherapy group. In the adjuvant setting, both systems failed to predict all outcomes. In the salvage setting, only the NCCN system significantly predicted biochemical-relapse-free-survival, metastasis-free-survival and disease-free-survival.

CONCLUSION

This analysis confirms the efficacy of both systems in definitive radiotherapy and suggests the utility of the NCCN also in salvage radiotherapy.

Distress evaluation in a veteran affairs oncology clinic

Distress in oncology patients (pts) has a negative impact on quality of life, survival, and healthcare satisfaction. Higher distress leads to lower compliance with treatment and follow-up [1-8]. The 2012 American College of Surgeons Commission on Cancer (CoC) standard of care for oncology pts included an assessment for distress [1]. A screening process for distress allows the healthcare team to address these issues early and refer to appropriate resources [2-9]. This project was initiated to meet National Comprehensive Cancer Network (NCCN) and CoC standard of care, identify distress in veterans with cancer, and address these concerns. Patients who attended the Tuesday oncology clinic at the Dayton VAMC were given the NCCN Distress Thermometer (DT) during triage. The treating physician addressed problems identified. The Wilcoxon signed rank test and the Friedman test were used. DTs were completed by 296 pts from March to December 2016. Mean age was 68, 93% male, 83% white, 55% married, and 93% without PTSD. The distress level was not different from T1 through T3. Number of problems decreased over three time periods. Referrals to nutrition, mental health, and social work services increased over time. Although over time periods we found no decrease in distress scores, there was a decline in number of problems. The mean distress score at all but time 4 was < 4, which is considered mild distress. The mean distress score at T4 was 4.36 (n = 14), suggesting that the few pts who return to clinic more than three times may be experiencing more difficult personal and environmental circumstances. Patient sample ranged from those undergoing intensive cancer treatment (e.g., chemotherapy) to less intensive treatment (e.g., hormone injections) to those who completed treatment.

Review of Indications of FDA-Approved Immune Checkpoint Inhibitors per NCCN Guidelines with the Level of Evidence

Cancer is associated with higher morbidity and mortality and is the second leading cause of death in the US. Further, in some nations, cancer has overtaken heart disease as the leading cause of mortality. Identification of molecular mechanisms by which cancerous cells evade T cell-mediated cytotoxic damage has led to the modern era of immunotherapy in cancer treatment. Agents that release these immune brakes have shown activity to recover dysfunctional T cells and regress various cancer. Both cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and Programmed Death-1 (PD-1) play their role as physiologic brakes on unrestrained cytotoxic T effector function. CTLA-4 (CD 152) is a B7/CD28 family; it mediates immunosuppression by indirectly diminishing signaling through the co-stimulatory receptor CD28. Ipilimumab is the first and only FDA-approved CTLA-4 inhibitor; PD-1 is an inhibitory transmembrane protein expressed on T cells, B cells, Natural Killer cells (NKs), and Myeloid-Derived Suppressor Cells (MDSCs). Programmed Death-Ligand 1 (PD-L1) is expressed on the surface of multiple tissue types, including many tumor cells and hematopoietic cells. PD-L2 is more restricted to hematopoietic cells. Blockade of the PD-1 /PDL-1 pathway can enhance anti-tumor T cell reactivity and promotes immune control over the cancerous cells. Since the FDA approval of ipilimumab (human IgG1 k anti-CTLA-4 monoclonal antibody) in 2011, six more immune checkpoint inhibitors (ICIs) have been approved for cancer therapy. PD-1 inhibitors nivolumab, pembrolizumab, cemiplimab and PD-L1 inhibitors atezolizumab, avelumab, and durvalumab are in the current list of the approved agents in addition to ipilimumab. In this review paper, we discuss the role of each immune checkpoint inhibitor (ICI), the landmark trials which led to their FDA approval, and the strength of the evidence per National Comprehensive Cancer Network (NCCN), which is broadly utilized by medical oncologists and hematologists in their daily practice.

White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology's disease-focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive gastrointestinal malignancy with a poor 5-year survival rate. Accurate staging of PDAC is an important initial step in the development of a stage-specific treatment plan. Different staging systems/consensus statements convened by different societies and academic practices are currently used. The most recent version of the American Joint Committee on Cancer (AJCC) tumor/node/metastases (TNM) staging system for PDAC has shifted its focus from guiding management to assessing prognosis. In order to preoperatively define the resectability of PDAC and to guide management, additional classification systems have been developed. The National Comprehensive Cancer Network (NCCN) guidelines, one of the most commonly used systems, provide recommendations on the management and the determination of resectability for PDAC. The NCCN divides PDAC into three categories of resectability based on tumor-vessel relationship: 'resectable,' 'borderline resectable,' and 'unresectable'. Among these, the borderline disease category is of special interest given its evolution over time and the resulting variations in the definition and the associated recommendations for management between different societies. It is important to be familiar with the evolving criteria, and treatment and follow-up recommendations for PDAC. In this article, the most current AJCC staging (8th edition), NCCN guidelines (version 2.2019-April 9, 2019), and challenges and controversies in borderline resectable PDAC are reviewed.

Rate of BRCA mutation in patients tested under NCCN genetic testing criteria

BACKGROUND

BRCA genetic testing is recommended by the National Comprehensive Cancer Network (NCCN) in breast cancer patients who meet specific criteria. Limited data are available on the likelihood of detecting a mutation when these guidelines are followed.

METHODS

A retrospective chart review examined patients with breast cancer who underwent BRCA testing based on NCCN guidelines.

RESULTS

Twelve (6.0%) of the 199 patients had a deleterious BRCA mutation. Family history of BRCA mutations (50%, p = 0.019), age ≤45 at diagnosis (9.7%, p = 0.034) and meeting ≥3 NCCN criteria (13.3%, p = 0.03) yielded the highest rates of BRCA mutation. Having a family history of BRCA mutation and age ≤45 were associated with increased rate of BRCA mutation on multivariate analysis (OR 14.3, CI 1.2-166.3; OR 11.6, CI 1.2-108.6).

CONCLUSION

Select NCCN criteria are associated with higher rates of BRCA mutations. Waiting for genetic testing results to guide surgical management may be warranted in this subset of patients.

Real transparency in medicine: Time to act

Current methods of recording and reporting financial conflicts of interest are flawed and often result in inaccurate and inconsistent reporting by well‐intentioned individuals. To that end, this editorial identifies a number of specific current challenges for conflict‐of‐interest reporting along with potential solutions.

Grey areas and evidence gaps in the management of rectal cancer as revealed by comparing recommendations from clinical guidelines

BACKGROUND

While the management of nonmetastatic and oligometastatic rectal cancer has rapidly evolved over the last few decades, many grey areas and highly debated topics remain that foster significant variation in clinical practice. We aimed to identify controversial points and evidence gaps in this disease setting by systematically comparing recommendations from national and international clinical guidelines.

METHODS

Twenty-six clinical questions reflecting practical challenges in the routine management of nonmetastatic and oligometastatic rectal cancer patients were selected. Recommendations from the ESMO, NCCN, JSCCR, Australian and Ontario guidelines were extrapolated and compared using a 4-tier classification system (i.e., identical/very similar, similar, slightly different, different). Overall agreement between guidelines (i.e., substantial/complete disagreement, partial disagreement, partial agreement, substantial/complete agreement) was assessed for each clinical question and compared against the highest level of available evidence by using the χ² statistic test.

RESULTS

Guidelines were in substantial/complete agreement, partial agreement, partial disagreement, and substantial/complete disagreement for 8 (30.8%), 2 (7.7%), 7 (26.9%), and 9 (34.6%) clinical questions, respectively. High level of evidence supported clinical recommendations in 3/10 cases (30%) where guidelines were in agreement and in 10/16 cases (62.5%) where guidelines were in disagreement (χ² = 2.6, p = 0.106). Agreement was frequently reached for questions regarding diagnosis, staging, and radiology/pathology pro-forma reporting, while disagreement characterised most of the treatment-related topics.

CONCLUSIONS

Substantial variation exists across clinical guidelines in the recommendations for the management of nonmetastatic and oligometastatic rectal cancer. This variation is only partly explained by the lack of supporting, high-level evidence.

Population-based assessment of the National Comprehensive Cancer Network recommendations for baseline imaging of rectal cancer

Aim: To examine the performance characteristics of alternative criteria for baseline staging, in a cohort of contemporary rectal cancer patients from the Surveillance, Epidemiology and End Results (SEER) database. Methods: The SEER database (2010-2015) was accessed and patients with rectal cancer plus complete information on clinical T and N stages as well as metastatic sites were evaluated. We examined various performance characteristics of baseline imaging, including specificity, sensitivity, number needed to investigate (NNI), positive predictive value (PPV), negative predictive value and accuracy. Results: A total of 15,836 rectal cancer patients were included. Based on current guidelines that suggest cross-sectional chest and abdominal imaging for all cases of invasive rectal cancer, these recommendations would yield a PPV of 11.9% for the detection of liver metastases and 6.2% for the detection of lung metastases. This would translate to an NNI of 8.4 for liver metastases and an NNI of 16.1 for lung metastases. When patients with T1N0 were excluded from routine imaging, this resulted in a PPV of 6.4% and an NNI of 15.6 to identify one case of lung metastasis. Likewise, this resulted in a PPV of 12.3% and an NNI of 8.0 to detect one case of liver metastasis. Similarly, when patients with either T1N0 or T2N0 were excluded from routine imaging, the PPV and NNI for lung metastases improved to 6.6% and 15.1, respectively, and the PPV and NNI for liver metastases improved to 12.6 and 7.9%, respectively. Conclusion: Our study suggests that the specificity of the current imaging approach for rectal cancer staging is limited and that the omission of chest and abdominal imaging among selected early stage asymptomatic cases may be reasonable to consider.

Is routine baseline brain imaging needed for all newly diagnosed non-small-cell lung cancer patients?

Aim: Dedicated brain imaging is advocated by the National Comprehensive Cancer Network guidelines for newly diagnosed non-small-cell cancer (NSCLC) patients beyond stage I. The current study assessed the performance characteristics of this recommendation. Methods: Through accessing the Surveillance, Epidemiology and End Points (SEER) registry (2010-2015), all patients (regardless of stage) with newly diagnosed NSCLC and complete information about TN stages and presence or absence of brain metastases were extracted. In the current study, the following performance characteristics of the above recommendation were assessed: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), number needed to investigate (NNI) and accuracy. Results: A total of 182,977 NSCLC patients were included. For the overall cohort, PPV (for the recognition of brain metastases) was 13.8% and NNI to detect one case of brain metastasis was 7.2. Likewise, NPV (for the exclusion of brain metastases) was 97%, sensitivity was 92.1%, specificity was 31.1% and overall accuracy was 37.6%. When stratified by histology, patients with adenocarcinoma have PPV of 17.2% and NNI to detect one case with brain metastasis of 5.8. NPV (for the exclusion of brain metastases) was 97%, sensitivity of 91.4%, specificity of 35.4% and overall accuracy of 32.6%. On the other hand, patients with squamous cell carcinoma have PPV of 6.3% and NNI to detect one case with brain metastasis of 15.8. NPV (for the exclusion of brain metastases) was 98.9%, sensitivity of 94.6%, specificity of 26.3% and overall accuracy of 29.7%. Conclusion: In view of the poor specificity, the current study calls for reconsideration of the universal recommendation of dedicated brain imaging (in addition to PET/CT scan) among NSCLC patients beyond stage I.

The future of lung cancer therapy: Striding beyond conventional EGFR and ALK treatments

Lung cancer, one of the most frequently diagnosed cancers worldwide has long relied on testing for the molecular biomarkers EGFR/ALK. However, achieving superior clinical outcomes for patients with lung cancer requires developing comprehensive techniques beyond contemporary EGFR/ALK testing. Current technologies are on par with molecular testing for EGFR/ALK in terms of efficacy, most of them failing to offer improvements perhaps primarily due to skepticism among clinicians, despite being recommended in the NCCN guidelines. The present study endeavored to minimize chemotherapy-dependence in EGFR/ALK-negative patient cohorts, and use evidence-based methods to identify ways to improve clinical outcomes. In total, 137 lung cancer cases obtained from 'PositiveSelect NGS data', comprising 91 males and 46 females, were investigated. EGFR- and ALK-positivity was used for data dichotomization to understand the therapeutic utility of rare gene alterations beyond just EGFR/ALK. Statistics obtained from PositiveSelect were collated with data from international studies to construct a meta-analysis intended to achieve better clinical outcomes. Upon dichotomization, 23% of cases harbored EGFR variants indicating that treating with EGFR TKIs would be beneficial; the remaining 77% exhibited no EGFR variants that would indicate favorable results using specific currently available chemotherapy practices. Similarly, 28% of cases had EGFR+ALK variants favoring EGFR/ALK-based targeted therapeutics; the remaining 72% harbored no EGFR/ALK variants with known beneficial chemotherapy routes. The present study aimed to overcome current inadequacies of targeted therapies in patients with a conventional EGFR/ALK-positive diagnosis and those in EGFR+ALK-negative cohorts. Upon analysis of the negative cohorts, significant and clinically relevant single nucleotide variants were identified in KRAS, ERBB2, MET and RET, with frequencies of 7, 1, 2 and 3% in patients who were EGFR-negative and 6, 1, 1, and 3% in patients who were EGFR and ALK-negative, respectively, enabling the use of targeted therapeutics aside from EGFR/ALK TKIs. From the results of the current study only 35% of the two negative arms (EGFR negative and EGFR+ALK negative) would be recommended NCCN or off-label chemotherapy; prior to the current study, the entire cohorts would have been recommended this treatment. The present study emphasizes the potential of comprehensive genomics in identifying hallmarks of lung cancer beyond EGFR/ALK, using broad-spectrum genetic testing and data-sharing among medical professionals to circumvent ineffective chemotherapy.

Population-based assessment of the national comprehensive cancer network recommendations for baseline imaging of hepatocellular carcinoma

This analysis aims to evaluate the performance characteristics of alternative baseline imaging thresholds in a cohort of hepatocellular carcinoma (HCC) patients from the Surveillance, Epidemiology, and End Results (SEER) database. HCC patients within the SEER database (2010-2015) who had complete information on clinical T and N stages as well as complete information on metastatic sites were eligible for the current study. Various performance characteristics associated with baseline imaging were investigated, including specificity, sensitivity, positive likelihood ratio (LR), negative LR, number needed to investigate (NNI), negative predictive value (NPV), positive predictive value (PPV), and accuracy. A total of 27,201 HCC patients were included. Based on current recommendations that advocate for the use of cross-sectional chest imaging in all newly diagnosed cases of HCC, these recommendations would yield a PPV of 5.0% for the detection of lung metastases. This would translate to an NNI of 20.0. When T1N0 patients were excluded from routine chest or bone imaging, this resulted in a PPV of 6.8% for the identification of lung metastases and an NNI of 14.7. Likewise, this translated to a PPV of 4.6% for the identification of bone metastases and an NNI of 21.7. Similarly, when patients with T1N0 disease and normal alpha-fetoprotein (AFP) were excluded from routine imaging, this resulted in a PPV of 5.6% for the identification of lung metastases and an NNI of 17.8. Also, this translated to a PPV of 3.8% for the identification of bone metastases and an NNI of 26.3. The current study suggests that the omission of routine baseline chest imaging may be considered in selected patients with asymptomatic early-stage HCC and normal AFP.

Population-based validation of the National Comprehensive Cancer Network recommendations for baseline imaging for bladder cancer: a case for routine baseline bone scan?

AIM

This study aims at evaluating the performance of some of the imaging recommendations of the National Comprehensive Cancer Network (NCCN) for initial evaluation of bladder cancer.

METHODS

Surveillance, epidemiology and end results program (2010-2015) was queried and patients with clinically (T1-T4) bladder cancer and complete information about clinical T/N (tumor/nodal) stage and metastatic sites were extracted. The following characteristics were evaluated in the current analysis: sensitivity, specificity, number needed to investigate (NNI), positive predictive value (PPV), negative predictive value and accuracy.

RESULTS

According to the current NCCN guidelines, PPV (for the recognition of lung metastases) is 4.7% and NNI to detect one case of lung metastasis is 21.2. Similarly, PPV (for the recognition of liver metastases) is 3.1% and NNI to detect one case of liver metastasis is 32.2. Using a different imaging threshold (i.e., routinely imaging all patients >T2N0), PPV (for the recognition of lung metastases) is 10.4% and NNI to detect one case of lung metastasis is 9.6. Similarly, PPV (for the recognition of liver metastases) is 7% and NNI to detect one case of liver metastasis is 14.2. The above two thresholds were also evaluated for routine bone scanning. PPV (for the detection of one case of bone metastasis) is 5.3% using the first threshold and 11.2% using the second threshold.

CONCLUSION

Imaging per current NCCN guidelines results in few patients with undetected asymptomatic lung or liver metastases. A routine baseline bone scan should be additionally considered for some asymptomatic patients with muscle-invasive disease.

Population-based validation of the National Cancer Comprehensive Network recommendations for breast cancer staging

OBJECTIVE

The aim of the current study is to evaluate the performance characteristics of the National Comprehensive Cancer Network (NCCN) staging recommendations for breast cancer with regard to the detection of lung, bone, and liver metastases.

METHODS

Surveillance, epidemiology, and end points (SEER) database (2010-2015) was accessed, and patients with breast cancer and complete information about T stage and clinical N stage, ER status, Her2 status, and metastatic sites were extracted. Performance characteristics evaluated for the current study included sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), number needed to investigate (NNI), and accuracy.

RESULTS

A total of 239,196 patients were included in the analysis. For the overall cohort, the required PPV (for the recognition of lung metastases) is 10.6% and NNI to detect one case of lung metastasis is 9.4. Likewise, PPV (for the recognition of bone metastases) is 18.6% and NNI to detect one case of bone metastasis is 5.3. Moreover, PPV (for the recognition of liver metastases) is 7.6% and NNI to detect one case of liver metastasis is 13.1. When changing the threshold for baseline imaging to includeT2N1 patients, a better balance between sensitivity and specificity among ER+/Her2- patients (> 92% for both sensitivity and specificity for the three metastatic sites) was observed. On the other hand, the proposed change improved sensitivity while it lowers significantly the specificity among Her2+ and triple negative subtypes (specificity < 84% for Her2+ disease for the three metastatic sites; specificity < 87% for triple negative disease for the three metastatic sites).

CONCLUSION

The current NCCN recommendations for breast cancer staging have an excellent NPV and miss only few patients with lung, liver, or bone metastases. Future studies incorporating the subtype of breast cancer as a determinant of staging pathway is needed.

Applicability of current NCCN Guidelines for pancreatic adenocarcinoma resectability: analysis and pitfalls

PURPOSE

To test the applicability of National Comprehensive Cancer Network (NCCN v 3.2017) resectability criteria for pancreatic ductal adenocarcinoma (PDAC) in clinical practice, at a high-volume tertiary referral center.

MATERIALS AND METHODS

102 consecutive patients (53 female; mean age 66.2 years, range 34-90 years) with biopsy proven, non-metastatic PDAC were evaluated by our multidisciplinary pancreatic cancer program between July 2013 and February 2016. Retrospective review of staging pancreatic CT angiography was performed, and radiographic features were categorized as conforming to or non-conforming to existing v 3.2017 definitions.

RESULTS

Among 102 patients, 10 (10%) had CTA evidence of vascular involvement that did not conform to existing NCCN Guidelines. Six new scenarios of vascular involvement were identified. The remaining 92 patients presented with resectable (n = 20 [22%]), borderline resectable (n = 42 [45.6%]), or unresectable (n = 30 [33%]) PDAC. Approximately half (n = 21 [51%]) of borderline resectable patients' tumors demonstrated isolated venous involvement, whereas 39% had both arterial and venous involvement. A minority (11%) demonstrated only major arterial involvement. Assignment to unresectable status reflected both arterial and venous involvement (11, 37%), arterial involvement only (10, 33%) patients, and unreconstructible venous involvement in 9 (30%).

CONCLUSION

In our experience, current NCCN resectability guidelines for PDAC do not accurately classify vascular involvement identified in approximately 10% of patients. Revision of the current guidelines could be helpful to clinical practice.

Determining Adequate Margins in Head and Neck Cancers: Practice and Continued Challenges

Margin assessment remains a critical component of oncologic care for head and neck cancer patients. As an integrated team, both surgeons and pathologists work together to assess margins in these complex patients. Differences in method of margin sampling can impact obtainable information and effect outcomes. Additionally, what distance is an "adequate or clear" margin for patient care continues to be debated. Ultimately, future studies and potentially secondary modalities to augment pathologic assessment of margin assessment (i.e., in situ imaging or molecular assessment) may enhance local control in head and neck cancer patients.

Experience With a CT Screening Program for Individuals at High Risk for Developing Lung Cancer

PURPOSE

The aim of this study was to compare results of National Comprehensive Cancer Network (NCCN) high-risk group 2 with those of NCCN high-risk group 1 in a clinical CT lung screening program.

METHODS

The results of consecutive clinical CT lung screening examinations performed from January 2012 through December 2013 were retrospectively reviewed. All examinations were interpreted by radiologists credentialed in structured CT lung screening reporting, following the NCCN Clinical Practice Guidelines in Oncology: Lung Cancer Screening (version 1.2012). Positive results required a solid nodule ≥4 mm, a ground-glass nodule ≥5 mm, or a mediastinal or hilar lymph node >1 cm, not stable for >2 years. Significant incidental findings and findings suspicious for pulmonary infection were also recorded.

RESULTS

A total of 1,760 examinations were performed (464 in group 2, 1,296 in group 1); no clinical follow-up was available in 432 patients (28%). Positive results, clinically significant incidental findings, and suspected pulmonary infection were present in 25%, 6%, and 6% in group 2 and 28.2%, 6.2%, and 6.6% in group 1, respectively. Twenty-three cases of lung cancer were diagnosed (6 in group 2, 17 in group 1), for annualized rates of malignancy of 1.8% in group 2 and 1.6% in group 1.

CONCLUSION

NCCN group 2 results were substantively similar to those for group 1 and closely resemble those reported in the National Lung Screening Trial. Similar rates of positivity and lung cancer diagnosis in both groups suggest that thousands of additional lives may be saved each year if screening eligibility is expanded to include this particular high-risk group.

What is the Asian Consensus Statement on NCCN clinical practice guidelines in oncology (NCCN-ACS)?

Cancer treatment guidelines are compiled on the basis of established evidence. Such evidence is obtained from epidemiological, pathological and pharmacological study and, most importantly of all, the information gained from clinical trials. However, very little of the kind of evidence that is required for the compilation of treatment guidelines is actually obtained from Asian countries. When one considers the ethnic differences and disparities in medical care, coupled with the tremendous cultural diversity that characterize the Asian region, it would be difficult to conclude that there is currently sufficient evidence that could form the basis for the formulation of guidelines that would be relevant and applicable to all Asian countries. An urgent issue that needs to be addressed in order to achieve a breakthrough in this difficult situation is to build up a body of evidence at an advanced level that is specific to the Asian region and Asian ethnicities. For the interim, however, it is also necessary to efficiently incorporate evidence that has been obtained in Western countries. Furthermore, an effective method of utilizing guidelines that have already been compiled in Western countries is considered to be not by simply translating them into local languages, but rather to engage in a process of adaptation, whereby the guidelines are adjusted or modified to match the circumstances of a particular country or region. The NCCN Clinical Practice Guidelines-Asian Consensus Statement (NCCN-ACS) documents have been compiled with this intention in mind, utilizing the NCCN guidelines that are widely used internationally.

Socioeconomic status as a predictor of adherence to treatment guidelines for early-stage ovarian cancer

OBJECTIVE

Investigate the impact of socioeconomic status and other demographic variables on adherence to the National Comprehensive Cancer Network ovarian cancer treatment guidelines among patients with stage I/II disease.

METHODS

Patients diagnosed with stage I/II epithelial ovarian cancer between 1/1/96-12/31/06 were identified from the California Cancer Registry. Univariate analysis and multivariate logistic regression models were used to evaluate differences in surgical procedures, chemotherapy regimens, and overall adherence to the NCCN guidelines according to increasing SES quintiles (SES-1 to SES-5).

RESULTS

A total of 5445 stage I and II patients were identified. The median age at diagnosis was 54.0years (range=18-99years); 72.5% of patients had stage I disease, while 27.5% had stage II disease. With a median follow-up time of 5years, the 5-year ovarian cancer-specific survival for all patients was 82.7% (SE=0.6%). Overall, 23.7% of patients received care that was adherent to the NCCN guidelines. Compared to patients in the highest SES quintile (SES-5), patients in the lowest SES quintile (SES-1) were significantly less likely to receive proper surgery (27.3% vs 47.9%, p<0.001) or chemotherapy (42.4% vs 53.6%, p<0.001). There were statistically significant trends between increasing SES and the likelihood of overall treatment plan adherence to the NCCN guidelines: SES-1=16.4%, SES-2=19.0%, SES-3=22.4%, SES-4=24.2% and SES-5=31.6% (p<0.001). Multivariate logistic regression analysis revealed that compared to SES-5, decreasing SES was independently predictive of a higher risk of non-standard overall care.

CONCLUSIONS

For patients with early-stage ovarian cancer, low SES is a significant and independent predictor of deviation from the NCCN guidelines for surgery, chemotherapy, and overall treatment.

Discrepancies between ESMO and NCCN breast cancer guidelines: An appraisal

An ever growing number of medical organizations, societies, working groups and governmental agencies issue algorithms i.e. guidelines, of decision making flowcharts in diagnosis and treatment in a variety of diseases. In the field of evidence-based diagnosis and treatment of breast cancer, a large number of guidelines are available both from medical associations and national health departments. Among the most appreciated and utilized comprehensive guides is the European Society for Medical Oncology (ESMO) Breast Cancer Guidelines and from the other side of the Atlantic the National Comprehensive Cancer Network (NCCN) Guidelines in Breast Cancer. Although there is much concordance between the guidelines from these two organizations, it is intriguing to locate their discrepancies also. The aim of this report is to present a number of different points between ESMO and NCCN in the whole spectrum of breast cancer management, from prevention and diagnosis to treatment and follow up. This systematic review was performed in accordance with the PRISMA guidelines using a predefined search strategy and summarizes in detail, the differences between ESMO and NCCN guidelines regarding genetic risk evaluation and screening, surgery, chemotherapy, endocrine treatment, targeted biological agents, radiotherapy, pregnancy and fertility and follow-up.

Experience with a CT screening program for individuals at high risk for developing lung cancer

PURPOSE

The aim of this study was to compare results of National Comprehensive Cancer Network (NCCN) high-risk group 2 with those of NCCN high-risk group 1 in a clinical CT lung screening program.

METHODS

The results of consecutive clinical CT lung screening examinations performed from January 2012 through December 2013 were retrospectively reviewed. All examinations were interpreted by radiologists credentialed in structured CT lung screening reporting, following the NCCN Clinical Practice Guidelines in Oncology: Lung Cancer Screening (version 1.2012). Positive results required a solid nodule ≥4 mm, a ground-glass nodule ≥5 mm, or a mediastinal or hilar lymph node >1 cm, not stable for >2 years. Significant incidental findings and findings suspicious for pulmonary infection were also recorded.

RESULTS

A total of 1,760 examinations were performed (464 in group 2, 1,296 in group 1); no clinical follow-up was available in 432 patients (28%). Positive results, clinically significant incidental findings, and suspected pulmonary infection were present in 25%, 6%, and 6% in group 2 and 28.2%, 6.2%, and 6.6% in group 1, respectively. Twenty-three cases of lung cancer were diagnosed (6 in group 2, 17 in group 1), for annualized rates of malignancy of 1.8% in group 2 and 1.6% in group 1.

CONCLUSION

NCCN group 2 results were substantively similar to those for group 1 and closely resemble those reported in the National Lung Screening Trial. Similar rates of positivity and lung cancer diagnosis in both groups suggest that thousands of additional lives may be saved each year if screening eligibility is expanded to include this particular high-risk group.

Metastatic colorectal cancer treatment patterns according to kirsten rat sarcoma viral oncogene homolog genotype in U.S. Community-based oncology practices

INTRODUCTION

In 2008, the National Comprehensive Cancer Network guidelines were revised in light of the identification of the Kirsten Rat Sarcoma Viral Oncogene Homolog (KRAS) gene as a biomarker of nonresponse to epidermal growth factor receptor inhibitors. This study sought to describe and compare real-world treatment patterns of metastatic colorectal cancer (mCRC) according to KRAS genotype in community-based oncology practices in the United States.

MATERIALS AND METHODS

Data from the ACORN (ACORN LLC, Memphis, TN) electronic medical record data warehouse, containing data of approximately 180,000 patients from 12 oncology practices across the United States were used. Records of adult patients with mCRC who had undergone KRAS testing between January 2008 and December 2011 were evaluated. Patient demographic characteristics, KRAS genotype, and treatment patterns were identified and compared.

RESULTS

Six hundred forty-eight mCRC patients who were tested for KRAS were identified. Of these, 48.1% had wild type (WT), 42.3% mutant, and 9.6% unknown genotypes. Most patients (72.1%) were tested in 2009 or later, after the guideline revision. Bevacizumab-containing combinations were the most common first-line regimens in KRAS mutant and WT patients. Approximately 90% of patients received at least 1 line of therapy, however, WT patients received significantly more lines of therapy than KRAS mutant patients (2.6 ± 1.5 vs. 2.1 ± 1.2; P < .001).

CONCLUSIONS

KRAS WT and mutant genotypes had similar first-line regimens; however, WT patients received more lines of therapy. Although there does not appear to be a lag between changes in guidelines and treatment practice, professional and government organizations must keep up with the changing science and disseminate this information to oncologists in a timely manner.

Primary cutaneous T-cell lymphoma (mycosis fungoides and Sézary syndrome): part II. Prognosis, management, and future directions

Both mycosis fungoides (MF) and Sézary syndrome (SS) have a chronic, relapsing course, with patients frequently undergoing multiple, consecutive therapies. Treatment is aimed at the clearance of skin disease, the minimization of recurrence, the prevention of disease progression, and the preservation of quality of life. Other important considerations are symptom severity, including pruritus and patient age/comorbidities. In general, for limited patch and plaque disease, patients have excellent prognosis on ≥1 topical formulations, including topical corticosteroids and nitrogen mustard, with widespread patch/plaque disease often requiring phototherapy. In refractory early stage MF, transformed MF, and folliculotropic MF, a combination of skin-directed therapy plus low-dose immunomodulators (eg, interferon or bexarotene) may be effective. Patients with advanced and erythrodermic MF/SS can have profound immunosuppression, with treatments targeting tumor cells aimed for immune reconstitution. Biologic agents or targeted therapies either alone or in combination--including immunomodulators and histone-deacetylase inhibitors--are tried first, with more immunosuppressive therapies, such as alemtuzumab or chemotherapy, being generally reserved for refractory or rapidly progressive disease or extensive lymph node and metastatic involvement. Recently, an increased understanding of the pathogenesis of MF and SS with identification of important molecular markers has led to the development of new targeted therapies that are currently being explored in clinical trials in advanced MF and SS.

Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the society of abdominal radiology and the american pancreatic association

Pancreatic ductal adenocarcinoma is an aggressive malignancy with a high mortality rate. Proper determination of the extent of disease on imaging studies at the time of staging is one of the most important steps in optimal patient management. Given the variability in expertise and definition of disease extent among different practitioners as well as frequent lack of complete reporting of pertinent imaging findings at radiologic examinations, adoption of a standardized template for radiology reporting, using universally accepted and agreed on terminology for solid pancreatic neoplasms, is needed. A consensus statement describing a standardized reporting template authored by a multi-institutional group of experts in pancreatic ductal adenocarcinoma that included radiologists, gastroenterologists, and hepatopancreatobiliary surgeons was developed under the joint sponsorship of the Society of Abdominal Radiologists and the American Pancreatic Association. Adoption of this standardized imaging reporting template should improve the decision-making process for the management of patients with pancreatic ductal adenocarcinoma by providing a complete, pertinent, and accurate reporting of disease staging to optimize treatment recommendations that can be offered to the patient. Standardization can also help to facilitate research and clinical trial design by using appropriate and consistent staging by means of resectability status, thus allowing for comparison of results among different institutions.