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NCCN: Stratify Acute Lymphoblastic Leukemia Patients by Age
Management of acute lymphoblastic leukemia should be driven in large part by patient age, according to new clinical practice guidelines issued by the National Comprehensive Cancer Network.
Adolescents and young adults between the ages of 15 and 39 years benefit from the intensive therapies used to treat children, while older adults are thought to be less tolerant of the high-dose pediatric regimens, explained Dr. Patrick A. Brown.
"At this point, multiple studies have indicated that young adults with acute lymphoblastic leukemia [ALL] benefit significantly from pediatric-inspired treatments, and the new guidelines reflect this," said Dr. Brown, cochair of the NCCN panel that wrote the guidelines.
The treatment of older adults, on the other hand, is compromised relative to their younger counterparts, not only by their diminished tolerance of high-dose therapies but also by the presence in many adults of cytogenic abnormalities, including the translocation that results in the Philadelphia (Ph) chromosome, said Dr. Brown, director of the Pediatric Leukemia Program at the Kimmel Comprehensive Cancer Canter, Johns Hopkins University, Baltimore.
The Ph chromosome, a common feature in adult ALL patients but rare in children, leads to formation of the BCR-ABL fusion gene that is associated with a poor prognosis independent of age, he noted in an interview.
The new guidelines were presented March 17 at the conference in Hollywood, Fla.
They call for initial patient stratification based on Ph status and treatment of Ph-positive ALL patients with regimens that incorporate BCR-ABL-targeting tyrosine kinase inhibitors, such as imatinib (Gleevec). Imatinib is FDA approved for the treatment of adult patients with relapsed or refractory Ph-positive ALL.
Regarding treatment decisions, the guidelines recommend risk stratification by age, with adolescent and young adult patients aged 15-39 years being considered separately from the adult population 40 years and older. The guidelines also advocate that those 65 years and older be considered separately as well, but caution that "chronological age alone is a poor surrogate for determining patient fitness for therapy."
Consideration of allogeneic stem cell transplantation as a consolidation option following induction therapy in ALL patients should be based on Ph status and age, Dr. Brown said, noting that the guidelines recommend it for Ph-positive patients as well as PH-negative patients younger than 65 years who have high-risk features. These include elevated white blood cell count, hypodiploidy, or rearrangements of the mixed-lineage leukemia gene, not including those adult patients with preclusive comorbidities, such as organ dysfunction.
The guidelines also recommend:
• Central nervous system prophylaxis and treatment, including cranial irradiation, intrathecal chemotherapy, or high-dose systemic chemotherapy, throughout the course of therapy, from induction through maintenance, to clear leukemic cells from CNS sites that cannot be accessed by systemic chemotherapy because of the blood-brain barrier.
• Postinduction consolidation comprising drug combinations similar to those used during the induction phase, such as high-dose methotrexate, cytarabine, mercaptopurine, and l-asparaginase.
• Extended maintenance therapy for all patients (except those with mature B-cell ALL in whom relapses rarely occur beyond 12 months), typically comprising daily mercaptopurine and weekly methotrexate, often with periodic vincristine and corticosteroids, for 2 years in adults and 2-3 years in children.
• The possible inclusion of novel, immune-based agents that target specific genetic abnormalities, such as the BCR-ABL selective tyrosine kinase inhibitors for Ph-positive ALL, the anti-CD20 monoclonal antibody rituximab (Rituxan) for CD20-expression B-cell lineage ALL, and the adenosine deaminase substrate nelarabine (Arranon) for T-cell lineage ALL.
The NCCN guidelines also incorporate recommendations for minimal residual disease evaluation, provision of supportive care, and management of treatment-associated toxicities.
While the survival outcomes associated with ALL have improved dramatically among children in recent years – the cure rate with current treatment regimens is approximately 80% – the long-term prognosis for adults with the disease is poor, with cure rates of 30-40%, according to NCCN ALL guidelines panel member Dr. Daniel J. DeAngelo.
"ALL is the rarest form of adult leukemia, and we still have a lot of unanswered questions," said Dr. DeAngelo of the Dana-Farber Cancer Institute, Boston. "For this reason, adult patients with the disease should be referred to specialized cancer treatment centers and should be enrolled in clinical trials whenever possible."
Dr. Brown disclosed no relevant conflicts of interest. Dr. DeAngelo disclosed relationships with Bristol-Myers Squibb, Novartis, and Sigma-Tau Pharmaceuticals. The full list of disclosures for the NCCN ALL Guidelines Panel members can be found at http://www.nccn.org.
Management of acute lymphoblastic leukemia should be driven in large part by patient age, according to new clinical practice guidelines issued by the National Comprehensive Cancer Network.
Adolescents and young adults between the ages of 15 and 39 years benefit from the intensive therapies used to treat children, while older adults are thought to be less tolerant of the high-dose pediatric regimens, explained Dr. Patrick A. Brown.
"At this point, multiple studies have indicated that young adults with acute lymphoblastic leukemia [ALL] benefit significantly from pediatric-inspired treatments, and the new guidelines reflect this," said Dr. Brown, cochair of the NCCN panel that wrote the guidelines.
The treatment of older adults, on the other hand, is compromised relative to their younger counterparts, not only by their diminished tolerance of high-dose therapies but also by the presence in many adults of cytogenic abnormalities, including the translocation that results in the Philadelphia (Ph) chromosome, said Dr. Brown, director of the Pediatric Leukemia Program at the Kimmel Comprehensive Cancer Canter, Johns Hopkins University, Baltimore.
The Ph chromosome, a common feature in adult ALL patients but rare in children, leads to formation of the BCR-ABL fusion gene that is associated with a poor prognosis independent of age, he noted in an interview.
The new guidelines were presented March 17 at the conference in Hollywood, Fla.
They call for initial patient stratification based on Ph status and treatment of Ph-positive ALL patients with regimens that incorporate BCR-ABL-targeting tyrosine kinase inhibitors, such as imatinib (Gleevec). Imatinib is FDA approved for the treatment of adult patients with relapsed or refractory Ph-positive ALL.
Regarding treatment decisions, the guidelines recommend risk stratification by age, with adolescent and young adult patients aged 15-39 years being considered separately from the adult population 40 years and older. The guidelines also advocate that those 65 years and older be considered separately as well, but caution that "chronological age alone is a poor surrogate for determining patient fitness for therapy."
Consideration of allogeneic stem cell transplantation as a consolidation option following induction therapy in ALL patients should be based on Ph status and age, Dr. Brown said, noting that the guidelines recommend it for Ph-positive patients as well as PH-negative patients younger than 65 years who have high-risk features. These include elevated white blood cell count, hypodiploidy, or rearrangements of the mixed-lineage leukemia gene, not including those adult patients with preclusive comorbidities, such as organ dysfunction.
The guidelines also recommend:
• Central nervous system prophylaxis and treatment, including cranial irradiation, intrathecal chemotherapy, or high-dose systemic chemotherapy, throughout the course of therapy, from induction through maintenance, to clear leukemic cells from CNS sites that cannot be accessed by systemic chemotherapy because of the blood-brain barrier.
• Postinduction consolidation comprising drug combinations similar to those used during the induction phase, such as high-dose methotrexate, cytarabine, mercaptopurine, and l-asparaginase.
• Extended maintenance therapy for all patients (except those with mature B-cell ALL in whom relapses rarely occur beyond 12 months), typically comprising daily mercaptopurine and weekly methotrexate, often with periodic vincristine and corticosteroids, for 2 years in adults and 2-3 years in children.
• The possible inclusion of novel, immune-based agents that target specific genetic abnormalities, such as the BCR-ABL selective tyrosine kinase inhibitors for Ph-positive ALL, the anti-CD20 monoclonal antibody rituximab (Rituxan) for CD20-expression B-cell lineage ALL, and the adenosine deaminase substrate nelarabine (Arranon) for T-cell lineage ALL.
The NCCN guidelines also incorporate recommendations for minimal residual disease evaluation, provision of supportive care, and management of treatment-associated toxicities.
While the survival outcomes associated with ALL have improved dramatically among children in recent years – the cure rate with current treatment regimens is approximately 80% – the long-term prognosis for adults with the disease is poor, with cure rates of 30-40%, according to NCCN ALL guidelines panel member Dr. Daniel J. DeAngelo.
"ALL is the rarest form of adult leukemia, and we still have a lot of unanswered questions," said Dr. DeAngelo of the Dana-Farber Cancer Institute, Boston. "For this reason, adult patients with the disease should be referred to specialized cancer treatment centers and should be enrolled in clinical trials whenever possible."
Dr. Brown disclosed no relevant conflicts of interest. Dr. DeAngelo disclosed relationships with Bristol-Myers Squibb, Novartis, and Sigma-Tau Pharmaceuticals. The full list of disclosures for the NCCN ALL Guidelines Panel members can be found at http://www.nccn.org.
Management of acute lymphoblastic leukemia should be driven in large part by patient age, according to new clinical practice guidelines issued by the National Comprehensive Cancer Network.
Adolescents and young adults between the ages of 15 and 39 years benefit from the intensive therapies used to treat children, while older adults are thought to be less tolerant of the high-dose pediatric regimens, explained Dr. Patrick A. Brown.
"At this point, multiple studies have indicated that young adults with acute lymphoblastic leukemia [ALL] benefit significantly from pediatric-inspired treatments, and the new guidelines reflect this," said Dr. Brown, cochair of the NCCN panel that wrote the guidelines.
The treatment of older adults, on the other hand, is compromised relative to their younger counterparts, not only by their diminished tolerance of high-dose therapies but also by the presence in many adults of cytogenic abnormalities, including the translocation that results in the Philadelphia (Ph) chromosome, said Dr. Brown, director of the Pediatric Leukemia Program at the Kimmel Comprehensive Cancer Canter, Johns Hopkins University, Baltimore.
The Ph chromosome, a common feature in adult ALL patients but rare in children, leads to formation of the BCR-ABL fusion gene that is associated with a poor prognosis independent of age, he noted in an interview.
The new guidelines were presented March 17 at the conference in Hollywood, Fla.
They call for initial patient stratification based on Ph status and treatment of Ph-positive ALL patients with regimens that incorporate BCR-ABL-targeting tyrosine kinase inhibitors, such as imatinib (Gleevec). Imatinib is FDA approved for the treatment of adult patients with relapsed or refractory Ph-positive ALL.
Regarding treatment decisions, the guidelines recommend risk stratification by age, with adolescent and young adult patients aged 15-39 years being considered separately from the adult population 40 years and older. The guidelines also advocate that those 65 years and older be considered separately as well, but caution that "chronological age alone is a poor surrogate for determining patient fitness for therapy."
Consideration of allogeneic stem cell transplantation as a consolidation option following induction therapy in ALL patients should be based on Ph status and age, Dr. Brown said, noting that the guidelines recommend it for Ph-positive patients as well as PH-negative patients younger than 65 years who have high-risk features. These include elevated white blood cell count, hypodiploidy, or rearrangements of the mixed-lineage leukemia gene, not including those adult patients with preclusive comorbidities, such as organ dysfunction.
The guidelines also recommend:
• Central nervous system prophylaxis and treatment, including cranial irradiation, intrathecal chemotherapy, or high-dose systemic chemotherapy, throughout the course of therapy, from induction through maintenance, to clear leukemic cells from CNS sites that cannot be accessed by systemic chemotherapy because of the blood-brain barrier.
• Postinduction consolidation comprising drug combinations similar to those used during the induction phase, such as high-dose methotrexate, cytarabine, mercaptopurine, and l-asparaginase.
• Extended maintenance therapy for all patients (except those with mature B-cell ALL in whom relapses rarely occur beyond 12 months), typically comprising daily mercaptopurine and weekly methotrexate, often with periodic vincristine and corticosteroids, for 2 years in adults and 2-3 years in children.
• The possible inclusion of novel, immune-based agents that target specific genetic abnormalities, such as the BCR-ABL selective tyrosine kinase inhibitors for Ph-positive ALL, the anti-CD20 monoclonal antibody rituximab (Rituxan) for CD20-expression B-cell lineage ALL, and the adenosine deaminase substrate nelarabine (Arranon) for T-cell lineage ALL.
The NCCN guidelines also incorporate recommendations for minimal residual disease evaluation, provision of supportive care, and management of treatment-associated toxicities.
While the survival outcomes associated with ALL have improved dramatically among children in recent years – the cure rate with current treatment regimens is approximately 80% – the long-term prognosis for adults with the disease is poor, with cure rates of 30-40%, according to NCCN ALL guidelines panel member Dr. Daniel J. DeAngelo.
"ALL is the rarest form of adult leukemia, and we still have a lot of unanswered questions," said Dr. DeAngelo of the Dana-Farber Cancer Institute, Boston. "For this reason, adult patients with the disease should be referred to specialized cancer treatment centers and should be enrolled in clinical trials whenever possible."
Dr. Brown disclosed no relevant conflicts of interest. Dr. DeAngelo disclosed relationships with Bristol-Myers Squibb, Novartis, and Sigma-Tau Pharmaceuticals. The full list of disclosures for the NCCN ALL Guidelines Panel members can be found at http://www.nccn.org.
FROM THE ANNUAL CONFERENCE OF THE NATIONAL COMPREHENSIVE CANCER NETWORK
NCCN Reaffirms Lung Cancer Screening of Heavy Smokers
The benefits of routine lung cancer screening in high-risk individuals outweigh the potential risks, according to members of a National Comprehensive Cancer Network guidelines panel that recommended low-dose helical CT screening of two high-risk groups.
Mary E. Reid, Ph.D., of the Roswell Park Cancer Institute in Buffalo, N.Y., acknowledged the burdens – in particular, the cost and requisite resource utilization – associated with following all high-risk patients who screen positive. But, she said, "the evidence [in favor of] the recommendations is really strong and supports their implementation."
Lung cancer, she noted, is the only one of the top four deadliest cancers (lung, prostate, breast, and colorectal) that is not currently subject to routine screening.
Dr. Reid and colleagues on the National Comprehensive Cancer Network (NCCN) Guidelines Panel for Lung Cancer Screening presented the update at the NCCN annual conference March 14-18 in Hollywood, Fla. It had been issued in October 2011 and followed a New England Journal of Medicine report that low-dose CT screening of heavy smokers reduced lung cancer mortality by 20%, compared with annual chest x-rays, in the National Lung Screening Trial (NLST).
The revised guidelines recommend annual low-dose helical CT screening for the following two groups of high-risk individuals:
• Those aged 55-74 years with a minimum smoking history of 30 pack-years who either are current smokers or quit within the past 15 years.
• Those aged 50 years or older with a minimum smoking history of 20 pack-years plus one additional lung cancer risk factor, excluding secondhand smoke exposure.
Evidence from the randomized, controlled NLST suggests that early detection via screening reduced lung-cancer specific mortality in the former risk group, which characterizes the NLST patient population. Specifically, 1 in 100 high-risk individuals who were enrolled in the study screened positive on their first low-dose CT exam, and one life was saved for every 320 high-risk individuals screened over 2 years (three screens) (N. Engl. J. Med. 2011;365:395-409). The NCCN recommendation for this group is category 1, the highest level.
The recommendation for annual screening in the second high-risk group is based on less-robust evidence and a nonuniform consensus of the NCCN panel members, Dr. Reid said. As such, it is a less-emphatic category 2B recommendation.
The NCCN screening recommendations have been deemed by some experts to be premature in the absence of cost-efficacy analysis, particularly because of the high false-positive rates observed in both the CT group (96.4%) and the radiography group (94.5%), as well as the potentially harmful effects of radiation exposure associated with low-dose CT screening.
Despite the favorable outcome of their study, the NLST authors stressed the need for rigorous cost-effectiveness analyses before the crafting of public policy recommendations. "The reductions in lung-cancer mortality must be weighed against the harms from positive screening results and overdiagnosis, as well as the costs," they wrote. "The cost component of low-dose CT screening includes not only the screening examination itself but also the diagnostic follow-up and treatment."
In addition to recommending appropriate candidates for routine screening and the proposed frequency of the scans, the new NCCN guidelines outline lung cancer risk factors, address the risks and benefits of screening as well as screening accuracy, and offer an algorithm for the evaluation and follow-up of positive screens.
Specifically, the guidelines recommend the following:
• Basing the frequency of low-dose CT in high-risk patients on the size and status (solid, nonsolid, part-solid, ground-glass, ground-glass opacity) of the nodule on baseline CT.
• Excising all nodules that increase in size or become solid or part-solid during follow-up.
• Considering PET with CT for nodules 8 mm or larger at baseline.
• Performing biopsy or excision of nodules that are suspicious for lung cancer, based on PET with CT findings.
• Reexamining within 1 month solid endobronchial nodules with low-dose CT immediately after vigorous coughing.
• Counseling smokers to quit.
The NCCN is the first professional organization to recommend routine low-dose CT screening for individuals who are considered to be at high-risk for lung cancer, according to Dr. Reid. Last summer, the International Association for the Study of Lung Cancer issued a call for physicians to discuss lung cancer screening with patients who match the high-risk smoking history of those enrolled in the NSLT.
Dr. Reid disclosed no financial conflicts of interest. Disclosures of the NCCN Guidelines Panel for Lung Cancer Screening are online.
Mary E. Reid, Ph.D., Roswell Park Cancer Institute, Lung cancer, NCCN, National Lung Screening Trial, NLST,
The benefits of routine lung cancer screening in high-risk individuals outweigh the potential risks, according to members of a National Comprehensive Cancer Network guidelines panel that recommended low-dose helical CT screening of two high-risk groups.
Mary E. Reid, Ph.D., of the Roswell Park Cancer Institute in Buffalo, N.Y., acknowledged the burdens – in particular, the cost and requisite resource utilization – associated with following all high-risk patients who screen positive. But, she said, "the evidence [in favor of] the recommendations is really strong and supports their implementation."
Lung cancer, she noted, is the only one of the top four deadliest cancers (lung, prostate, breast, and colorectal) that is not currently subject to routine screening.
Dr. Reid and colleagues on the National Comprehensive Cancer Network (NCCN) Guidelines Panel for Lung Cancer Screening presented the update at the NCCN annual conference March 14-18 in Hollywood, Fla. It had been issued in October 2011 and followed a New England Journal of Medicine report that low-dose CT screening of heavy smokers reduced lung cancer mortality by 20%, compared with annual chest x-rays, in the National Lung Screening Trial (NLST).
The revised guidelines recommend annual low-dose helical CT screening for the following two groups of high-risk individuals:
• Those aged 55-74 years with a minimum smoking history of 30 pack-years who either are current smokers or quit within the past 15 years.
• Those aged 50 years or older with a minimum smoking history of 20 pack-years plus one additional lung cancer risk factor, excluding secondhand smoke exposure.
Evidence from the randomized, controlled NLST suggests that early detection via screening reduced lung-cancer specific mortality in the former risk group, which characterizes the NLST patient population. Specifically, 1 in 100 high-risk individuals who were enrolled in the study screened positive on their first low-dose CT exam, and one life was saved for every 320 high-risk individuals screened over 2 years (three screens) (N. Engl. J. Med. 2011;365:395-409). The NCCN recommendation for this group is category 1, the highest level.
The recommendation for annual screening in the second high-risk group is based on less-robust evidence and a nonuniform consensus of the NCCN panel members, Dr. Reid said. As such, it is a less-emphatic category 2B recommendation.
The NCCN screening recommendations have been deemed by some experts to be premature in the absence of cost-efficacy analysis, particularly because of the high false-positive rates observed in both the CT group (96.4%) and the radiography group (94.5%), as well as the potentially harmful effects of radiation exposure associated with low-dose CT screening.
Despite the favorable outcome of their study, the NLST authors stressed the need for rigorous cost-effectiveness analyses before the crafting of public policy recommendations. "The reductions in lung-cancer mortality must be weighed against the harms from positive screening results and overdiagnosis, as well as the costs," they wrote. "The cost component of low-dose CT screening includes not only the screening examination itself but also the diagnostic follow-up and treatment."
In addition to recommending appropriate candidates for routine screening and the proposed frequency of the scans, the new NCCN guidelines outline lung cancer risk factors, address the risks and benefits of screening as well as screening accuracy, and offer an algorithm for the evaluation and follow-up of positive screens.
Specifically, the guidelines recommend the following:
• Basing the frequency of low-dose CT in high-risk patients on the size and status (solid, nonsolid, part-solid, ground-glass, ground-glass opacity) of the nodule on baseline CT.
• Excising all nodules that increase in size or become solid or part-solid during follow-up.
• Considering PET with CT for nodules 8 mm or larger at baseline.
• Performing biopsy or excision of nodules that are suspicious for lung cancer, based on PET with CT findings.
• Reexamining within 1 month solid endobronchial nodules with low-dose CT immediately after vigorous coughing.
• Counseling smokers to quit.
The NCCN is the first professional organization to recommend routine low-dose CT screening for individuals who are considered to be at high-risk for lung cancer, according to Dr. Reid. Last summer, the International Association for the Study of Lung Cancer issued a call for physicians to discuss lung cancer screening with patients who match the high-risk smoking history of those enrolled in the NSLT.
Dr. Reid disclosed no financial conflicts of interest. Disclosures of the NCCN Guidelines Panel for Lung Cancer Screening are online.
The benefits of routine lung cancer screening in high-risk individuals outweigh the potential risks, according to members of a National Comprehensive Cancer Network guidelines panel that recommended low-dose helical CT screening of two high-risk groups.
Mary E. Reid, Ph.D., of the Roswell Park Cancer Institute in Buffalo, N.Y., acknowledged the burdens – in particular, the cost and requisite resource utilization – associated with following all high-risk patients who screen positive. But, she said, "the evidence [in favor of] the recommendations is really strong and supports their implementation."
Lung cancer, she noted, is the only one of the top four deadliest cancers (lung, prostate, breast, and colorectal) that is not currently subject to routine screening.
Dr. Reid and colleagues on the National Comprehensive Cancer Network (NCCN) Guidelines Panel for Lung Cancer Screening presented the update at the NCCN annual conference March 14-18 in Hollywood, Fla. It had been issued in October 2011 and followed a New England Journal of Medicine report that low-dose CT screening of heavy smokers reduced lung cancer mortality by 20%, compared with annual chest x-rays, in the National Lung Screening Trial (NLST).
The revised guidelines recommend annual low-dose helical CT screening for the following two groups of high-risk individuals:
• Those aged 55-74 years with a minimum smoking history of 30 pack-years who either are current smokers or quit within the past 15 years.
• Those aged 50 years or older with a minimum smoking history of 20 pack-years plus one additional lung cancer risk factor, excluding secondhand smoke exposure.
Evidence from the randomized, controlled NLST suggests that early detection via screening reduced lung-cancer specific mortality in the former risk group, which characterizes the NLST patient population. Specifically, 1 in 100 high-risk individuals who were enrolled in the study screened positive on their first low-dose CT exam, and one life was saved for every 320 high-risk individuals screened over 2 years (three screens) (N. Engl. J. Med. 2011;365:395-409). The NCCN recommendation for this group is category 1, the highest level.
The recommendation for annual screening in the second high-risk group is based on less-robust evidence and a nonuniform consensus of the NCCN panel members, Dr. Reid said. As such, it is a less-emphatic category 2B recommendation.
The NCCN screening recommendations have been deemed by some experts to be premature in the absence of cost-efficacy analysis, particularly because of the high false-positive rates observed in both the CT group (96.4%) and the radiography group (94.5%), as well as the potentially harmful effects of radiation exposure associated with low-dose CT screening.
Despite the favorable outcome of their study, the NLST authors stressed the need for rigorous cost-effectiveness analyses before the crafting of public policy recommendations. "The reductions in lung-cancer mortality must be weighed against the harms from positive screening results and overdiagnosis, as well as the costs," they wrote. "The cost component of low-dose CT screening includes not only the screening examination itself but also the diagnostic follow-up and treatment."
In addition to recommending appropriate candidates for routine screening and the proposed frequency of the scans, the new NCCN guidelines outline lung cancer risk factors, address the risks and benefits of screening as well as screening accuracy, and offer an algorithm for the evaluation and follow-up of positive screens.
Specifically, the guidelines recommend the following:
• Basing the frequency of low-dose CT in high-risk patients on the size and status (solid, nonsolid, part-solid, ground-glass, ground-glass opacity) of the nodule on baseline CT.
• Excising all nodules that increase in size or become solid or part-solid during follow-up.
• Considering PET with CT for nodules 8 mm or larger at baseline.
• Performing biopsy or excision of nodules that are suspicious for lung cancer, based on PET with CT findings.
• Reexamining within 1 month solid endobronchial nodules with low-dose CT immediately after vigorous coughing.
• Counseling smokers to quit.
The NCCN is the first professional organization to recommend routine low-dose CT screening for individuals who are considered to be at high-risk for lung cancer, according to Dr. Reid. Last summer, the International Association for the Study of Lung Cancer issued a call for physicians to discuss lung cancer screening with patients who match the high-risk smoking history of those enrolled in the NSLT.
Dr. Reid disclosed no financial conflicts of interest. Disclosures of the NCCN Guidelines Panel for Lung Cancer Screening are online.
Mary E. Reid, Ph.D., Roswell Park Cancer Institute, Lung cancer, NCCN, National Lung Screening Trial, NLST,
Mary E. Reid, Ph.D., Roswell Park Cancer Institute, Lung cancer, NCCN, National Lung Screening Trial, NLST,
FROM THE ANNUAL CONFERENCE OF THE NATIONAL COMPREHENSIVE CANCER NETWORK
NCCN Cancer Guidelines Focus on Adolescent, Young Adult Needs
New guidelines from the National Comprehensive Cancer Network recognize adolescent and young adult cancer patients as a distinct group with needs that are not being met by routine care for adults or for children.
The adolescent and young adult (AYA) oncology guidelines call for referral of these patients to cancer centers specializing in their age group as well as the individual’s specific type of cancer. The guidelines advocate a host of supportive services, including psychosocial assessment and fertility preservation counseling.
AYA patients are diagnosed with cancer when 15-39 years of age. They account for more than 70,000 new cancers every year, and their 5-year survival rate is lower than that of any other age group, according to Dr. Peter F. Coccia, chair of the National Comprehensive Cancer Network (NCCN) panel that made the recommendations.
Dr. Coccia, section chief, hematology/oncology at the University of Nebraska Medical Center in Omaha, presented the new guidelines along with Bradley J. Zebrack, Ph.D., of the University of Michigan Comprehensive Cancer Center in Ann Arbor, during the annual conference of the NCCN in Hollywood, Fla.
The frequency and distribution of cancer types that affect patients in this age demographic differ from the range in the pediatric and adult oncology populations, Dr. Coccia said in an interview. The best outcomes for adolescent and young adult patients are seen in patients with "pediatric-type" cancers, such as acute lymphoblastic leukemia and bone and soft-tissue sarcomas. Patients with adult-onset cancers, such as breast and colon cancer, have the worst outcomes.
He attributed the lack of survival gains to low enrollment in clinical trials (approximately 10% of 15- to 19-year-old patients and 1%-2% of 20- to 39-year-old patients), insufficient health insurance, inconsistent access to routine health care – and thus limited access to early diagnosis and aggressive early therapy – and reduced compliance with prescribed treatments.
Further distinguishing this patient group are the unique, age-related social and developmental considerations, according to Dr. Zebrack. This is the period when individuals establish their identity. "They are separating from their parents, becoming more involved with peers and dating, developing a sexual identity, and making decisions about the education, careers, and families," he said.
With their cancer diagnosis, they are confronting mortality before they would otherwise have to and considering the possible loss of reproductive capacity, he elaborated. They are becoming more versus less dependent on their parents and their plans for the future are being disrupted.
All of these considerations warrant specialized oncology and support services that are designed to focus on the unique biological, clinical, psychosocial, and survivorship issues of the age group, according to the guidelines. "The distinct biology of disease as well as other age-related issues in the AYA population [fertility, long-term side effects, insurance/financial issues, transportation to clinic appointments, child care, psychosocial support, and adherence to therapy] should be considered in the treatment decision-making process," the authors wrote.
In addition to advising that AYA cancer patients be referred to cancer centers "with expertise and experience in treating patients in this age group and the cancers that affect them," the guidelines strongly encourage participation in clinical trials as a way to improve access to state-of-the art treatment and to provide critical insight into the optimal management for this group, according to Dr. Coccia.
The guidelines advise the following for AYA patients:
– Undergo a comprehensive assessment following the cancer diagnosis, including psychosocial assessment, discussion of infertility risks, options for fertility preservation, and genetic and familial risk assessment within 2 months of treatment initiation.
– Be managed by a multidisciplinary team comprising experts in cancer treatment and in specific developmental issues such as fertility, education, career development, employment, family planning, pregnancy, sexually transmitted diseases, and substance use.
– Be treated with aggressive therapy in the absence of contraindications, accompanied by appropriate management of symptoms and side effects to minimize treatment severity and toxicity.
– Be apprised at the time of diagnosis of the risk of infertility due to cancer treatment and be referred to a fertility preservation clinic within 24 hours when appropriate and desired.
– Be apprised of and evaluated for treatment-associated risks in the case of pregnancy and be referred to a gynecologic oncologist and perinatologist with expertise and knowledge of the physiological changes that occur during pregnancy.
– Undergo assessment for developmentally appropriate psychosocial and supportive care across multiple domains, including individual function (developmental, emotional, and behavioral issues); relationships (family, peer, and health care provider); socioeconomic issues; and supportive care interventions.
– Be offered interdisciplinary palliative and end-of-life care as needed to control symptoms, relieve suffering, and improve patient and family quality of life.
To address the increased risk of late effects related to cancer treatment and the risk for long-term effects among AYA cancer survivors, the guidelines recommend cardiovascular, pulmonary, neuroendocrine, renal, gonadal, and neuropsychological screening interventions adapted from the Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers, which are based on treatment exposure.
Of critical importance, according to Dr. Zebrack, "every member of the [management] team must be trained in how to communicate with teens and young adults to make sure all of their needs are understood and are being met."
Some members of the NCCN AYA Oncology Panel disclosed financial and research relationships with multiple companies.
New guidelines from the National Comprehensive Cancer Network recognize adolescent and young adult cancer patients as a distinct group with needs that are not being met by routine care for adults or for children.
The adolescent and young adult (AYA) oncology guidelines call for referral of these patients to cancer centers specializing in their age group as well as the individual’s specific type of cancer. The guidelines advocate a host of supportive services, including psychosocial assessment and fertility preservation counseling.
AYA patients are diagnosed with cancer when 15-39 years of age. They account for more than 70,000 new cancers every year, and their 5-year survival rate is lower than that of any other age group, according to Dr. Peter F. Coccia, chair of the National Comprehensive Cancer Network (NCCN) panel that made the recommendations.
Dr. Coccia, section chief, hematology/oncology at the University of Nebraska Medical Center in Omaha, presented the new guidelines along with Bradley J. Zebrack, Ph.D., of the University of Michigan Comprehensive Cancer Center in Ann Arbor, during the annual conference of the NCCN in Hollywood, Fla.
The frequency and distribution of cancer types that affect patients in this age demographic differ from the range in the pediatric and adult oncology populations, Dr. Coccia said in an interview. The best outcomes for adolescent and young adult patients are seen in patients with "pediatric-type" cancers, such as acute lymphoblastic leukemia and bone and soft-tissue sarcomas. Patients with adult-onset cancers, such as breast and colon cancer, have the worst outcomes.
He attributed the lack of survival gains to low enrollment in clinical trials (approximately 10% of 15- to 19-year-old patients and 1%-2% of 20- to 39-year-old patients), insufficient health insurance, inconsistent access to routine health care – and thus limited access to early diagnosis and aggressive early therapy – and reduced compliance with prescribed treatments.
Further distinguishing this patient group are the unique, age-related social and developmental considerations, according to Dr. Zebrack. This is the period when individuals establish their identity. "They are separating from their parents, becoming more involved with peers and dating, developing a sexual identity, and making decisions about the education, careers, and families," he said.
With their cancer diagnosis, they are confronting mortality before they would otherwise have to and considering the possible loss of reproductive capacity, he elaborated. They are becoming more versus less dependent on their parents and their plans for the future are being disrupted.
All of these considerations warrant specialized oncology and support services that are designed to focus on the unique biological, clinical, psychosocial, and survivorship issues of the age group, according to the guidelines. "The distinct biology of disease as well as other age-related issues in the AYA population [fertility, long-term side effects, insurance/financial issues, transportation to clinic appointments, child care, psychosocial support, and adherence to therapy] should be considered in the treatment decision-making process," the authors wrote.
In addition to advising that AYA cancer patients be referred to cancer centers "with expertise and experience in treating patients in this age group and the cancers that affect them," the guidelines strongly encourage participation in clinical trials as a way to improve access to state-of-the art treatment and to provide critical insight into the optimal management for this group, according to Dr. Coccia.
The guidelines advise the following for AYA patients:
– Undergo a comprehensive assessment following the cancer diagnosis, including psychosocial assessment, discussion of infertility risks, options for fertility preservation, and genetic and familial risk assessment within 2 months of treatment initiation.
– Be managed by a multidisciplinary team comprising experts in cancer treatment and in specific developmental issues such as fertility, education, career development, employment, family planning, pregnancy, sexually transmitted diseases, and substance use.
– Be treated with aggressive therapy in the absence of contraindications, accompanied by appropriate management of symptoms and side effects to minimize treatment severity and toxicity.
– Be apprised at the time of diagnosis of the risk of infertility due to cancer treatment and be referred to a fertility preservation clinic within 24 hours when appropriate and desired.
– Be apprised of and evaluated for treatment-associated risks in the case of pregnancy and be referred to a gynecologic oncologist and perinatologist with expertise and knowledge of the physiological changes that occur during pregnancy.
– Undergo assessment for developmentally appropriate psychosocial and supportive care across multiple domains, including individual function (developmental, emotional, and behavioral issues); relationships (family, peer, and health care provider); socioeconomic issues; and supportive care interventions.
– Be offered interdisciplinary palliative and end-of-life care as needed to control symptoms, relieve suffering, and improve patient and family quality of life.
To address the increased risk of late effects related to cancer treatment and the risk for long-term effects among AYA cancer survivors, the guidelines recommend cardiovascular, pulmonary, neuroendocrine, renal, gonadal, and neuropsychological screening interventions adapted from the Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers, which are based on treatment exposure.
Of critical importance, according to Dr. Zebrack, "every member of the [management] team must be trained in how to communicate with teens and young adults to make sure all of their needs are understood and are being met."
Some members of the NCCN AYA Oncology Panel disclosed financial and research relationships with multiple companies.
New guidelines from the National Comprehensive Cancer Network recognize adolescent and young adult cancer patients as a distinct group with needs that are not being met by routine care for adults or for children.
The adolescent and young adult (AYA) oncology guidelines call for referral of these patients to cancer centers specializing in their age group as well as the individual’s specific type of cancer. The guidelines advocate a host of supportive services, including psychosocial assessment and fertility preservation counseling.
AYA patients are diagnosed with cancer when 15-39 years of age. They account for more than 70,000 new cancers every year, and their 5-year survival rate is lower than that of any other age group, according to Dr. Peter F. Coccia, chair of the National Comprehensive Cancer Network (NCCN) panel that made the recommendations.
Dr. Coccia, section chief, hematology/oncology at the University of Nebraska Medical Center in Omaha, presented the new guidelines along with Bradley J. Zebrack, Ph.D., of the University of Michigan Comprehensive Cancer Center in Ann Arbor, during the annual conference of the NCCN in Hollywood, Fla.
The frequency and distribution of cancer types that affect patients in this age demographic differ from the range in the pediatric and adult oncology populations, Dr. Coccia said in an interview. The best outcomes for adolescent and young adult patients are seen in patients with "pediatric-type" cancers, such as acute lymphoblastic leukemia and bone and soft-tissue sarcomas. Patients with adult-onset cancers, such as breast and colon cancer, have the worst outcomes.
He attributed the lack of survival gains to low enrollment in clinical trials (approximately 10% of 15- to 19-year-old patients and 1%-2% of 20- to 39-year-old patients), insufficient health insurance, inconsistent access to routine health care – and thus limited access to early diagnosis and aggressive early therapy – and reduced compliance with prescribed treatments.
Further distinguishing this patient group are the unique, age-related social and developmental considerations, according to Dr. Zebrack. This is the period when individuals establish their identity. "They are separating from their parents, becoming more involved with peers and dating, developing a sexual identity, and making decisions about the education, careers, and families," he said.
With their cancer diagnosis, they are confronting mortality before they would otherwise have to and considering the possible loss of reproductive capacity, he elaborated. They are becoming more versus less dependent on their parents and their plans for the future are being disrupted.
All of these considerations warrant specialized oncology and support services that are designed to focus on the unique biological, clinical, psychosocial, and survivorship issues of the age group, according to the guidelines. "The distinct biology of disease as well as other age-related issues in the AYA population [fertility, long-term side effects, insurance/financial issues, transportation to clinic appointments, child care, psychosocial support, and adherence to therapy] should be considered in the treatment decision-making process," the authors wrote.
In addition to advising that AYA cancer patients be referred to cancer centers "with expertise and experience in treating patients in this age group and the cancers that affect them," the guidelines strongly encourage participation in clinical trials as a way to improve access to state-of-the art treatment and to provide critical insight into the optimal management for this group, according to Dr. Coccia.
The guidelines advise the following for AYA patients:
– Undergo a comprehensive assessment following the cancer diagnosis, including psychosocial assessment, discussion of infertility risks, options for fertility preservation, and genetic and familial risk assessment within 2 months of treatment initiation.
– Be managed by a multidisciplinary team comprising experts in cancer treatment and in specific developmental issues such as fertility, education, career development, employment, family planning, pregnancy, sexually transmitted diseases, and substance use.
– Be treated with aggressive therapy in the absence of contraindications, accompanied by appropriate management of symptoms and side effects to minimize treatment severity and toxicity.
– Be apprised at the time of diagnosis of the risk of infertility due to cancer treatment and be referred to a fertility preservation clinic within 24 hours when appropriate and desired.
– Be apprised of and evaluated for treatment-associated risks in the case of pregnancy and be referred to a gynecologic oncologist and perinatologist with expertise and knowledge of the physiological changes that occur during pregnancy.
– Undergo assessment for developmentally appropriate psychosocial and supportive care across multiple domains, including individual function (developmental, emotional, and behavioral issues); relationships (family, peer, and health care provider); socioeconomic issues; and supportive care interventions.
– Be offered interdisciplinary palliative and end-of-life care as needed to control symptoms, relieve suffering, and improve patient and family quality of life.
To address the increased risk of late effects related to cancer treatment and the risk for long-term effects among AYA cancer survivors, the guidelines recommend cardiovascular, pulmonary, neuroendocrine, renal, gonadal, and neuropsychological screening interventions adapted from the Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers, which are based on treatment exposure.
Of critical importance, according to Dr. Zebrack, "every member of the [management] team must be trained in how to communicate with teens and young adults to make sure all of their needs are understood and are being met."
Some members of the NCCN AYA Oncology Panel disclosed financial and research relationships with multiple companies.