National Comprehensive Cancer Network Clinical Practice Guidelines Research Articles

Standardized treatment of oral cancer under the guidance of clinical practice guidelines of National Comprehensive Cancer Network.

Oral cancer represents a serious public health problem affecting oral and system health with a high global incidence. Treatment strategies for oral cancer vary in different disciplines and are likely to be limited to certain doctor's personal experience. While clinical practice guidelines are considered to enable doctors to determine the most appropriate and consistent treatment strategy according to the patient's situation. National Comprehensive Cancer Network (NCCN) clinical practice guidelines have become the most prevalent in global clinical oncology practice. This article mainly focuses on cases to discuss the normalized treatment strategy for oral cancer in different stages based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Head and Neck Cancers, Version 3, 2024.

Black and Hispanic patient representation in NCCN-recommended systemic therapy regimens for endometrial cancer (015)

Objectives: Clinical trials inform standard clinical guidance for the treatment of gynecologic cancers, and minority recruitment is critical to reducing racial disparities. Our study’s primary objective was to describe how race and ethnicity were represented within publications selected as high-quality clinical evidence for the preferred systemic treatment regimens of endometrial cancer by the National Comprehensive Cancer Network (NCCN). Our secondary objective was to compare the race/ethnicity distribution among clinical trial participants to the CDC reported rates of endometrial cancer among Black and Hispanic patients between the years 1999 and 2017. Methods: NCCN Clinical Practice Guidelines for Uterine Neoplasms, Version 4.2021, were used to identify the studies cited to support the preferred agents for the systemic treatment of endometrial cancer. We excluded nontherapeutic studies, those reported in abstract only, and studies that evaluated regimens for cancers other than endometrial carcinoma. Race and ethnicity data were manually abstracted and pooled among studies reporting these data. We compared the distributions of race and ethnicity observed in these studies with that of incident cancer cases in the U.S. using the Chi-square test. National cancer statistics were obtained from CDC’s U.S. Cancer Statistics database (1999-2017). Results: A total of 13 references were cited as the data for systemic treatment of endometrial cancer by the NCCN. Ten studies of 1,280 patients met the inclusion criteria and were reviewed for race and ethnicity data (Figure 1). The majority of the studies were phase II trials. Only four publications (40%), with 706 patients, reported on race and/or ethnicity with highly variable language regarding race and ethnicity categories. Of these four studies, one included multiple non-colorectal cancers, including endometrial; however, race and ethnicity were not specified for the 13 endometrial cancer patients; thus, the study was excluded from further analysis. Of the remaining 664 patients, 49 identified as Black or African American, representing 7.4% of trial participants that reported on race. In contrast, the CDC data suggests that 9.9% of women with endometrial cancer identify as Black or African American (p<0.001). Only two studies described participants as Hispanic or Latino. Of the 589 patients enrolled in these studies, 18 patients (3.2%) identified as Hispanic or Latino, compared with 7.6% of women diagnosed with cancer in the US (p<0.001). Objectives: Clinical trials inform standard clinical guidance for the treatment of gynecologic cancers, and minority recruitment is critical to reducing racial disparities. Our study’s primary objective was to describe how race and ethnicity were represented within publications selected as high-quality clinical evidence for the preferred systemic treatment regimens of endometrial cancer by the National Comprehensive Cancer Network (NCCN). Our secondary objective was to compare the race/ethnicity distribution among clinical trial participants to the CDC reported rates of endometrial cancer among Black and Hispanic patients between the years 1999 and 2017. Methods: NCCN Clinical Practice Guidelines for Uterine Neoplasms, Version 4.2021, were used to identify the studies cited to support the preferred agents for the systemic treatment of endometrial cancer. We excluded nontherapeutic studies, those reported in abstract only, and studies that evaluated regimens for cancers other than endometrial carcinoma. Race and ethnicity data were manually abstracted and pooled among studies reporting these data. We compared the distributions of race and ethnicity observed in these studies with that of incident cancer cases in the U.S. using the Chi-square test. National cancer statistics were obtained from CDC’s U.S. Cancer Statistics database (1999-2017). Results: A total of 13 references were cited as the data for systemic treatment of endometrial cancer by the NCCN. Ten studies of 1,280 patients met the inclusion criteria and were reviewed for race and ethnicity data (Figure 1). The majority of the studies were phase II trials. Only four publications (40%), with 706 patients, reported on race and/or ethnicity with highly variable language regarding race and ethnicity categories. Of these four studies, one included multiple non-colorectal cancers, including endometrial; however, race and ethnicity were not specified for the 13 endometrial cancer patients; thus, the study was excluded from further analysis. Of the remaining 664 patients, 49 identified as Black or African American, representing 7.4% of trial participants that reported on race. In contrast, the CDC data suggests that 9.9% of women with endometrial cancer identify as Black or African American (p<0.001). Only two studies described participants as Hispanic or Latino. Of the 589 patients enrolled in these studies, 18 patients (3.2%) identified as Hispanic or Latino, compared with 7.6% of women diagnosed with cancer in the US (p<0.001).

Value of 68Ga-labeled bombesin antagonist (RM2) in the detection of primary prostate cancer comparing with [18F]fluoromethylcholine PET-CT and multiparametric MRI—a phase I/II study

ObjectivesThe bombesin derivative RM2 is a GRPr antagonist with strong binding affinity to prostate cancer (PCa). In this study, the impact of [68Ga]Ga-RM2 positron emission tomography-computed tomography (PET-CT) for the detection of primary PCa was compared with that of [18F]FCH PET-CT and multiparametric magnetic resonance imaging (mpMRI).MethodsThis phase I/II study was conducted in 30 biopsy-positive PCa subjects. The patients were stratified into high (10 patients), intermediate (10 patients), and low risk (10 patients) for extraglandular metastases as defined by National Comprehensive Cancer Network (NCCN) criteria (NCCN Clinical Practice Guidelines in Oncology, 2016). The prostate gland was classified in 12 anatomic segments for data analysis of the imaging modalities as well as histopathologic findings. The segment with the highest radiotracer uptake was defined as the “index lesion.” All cases were scheduled to undergo prostatectomy with pelvic lymph node (LN) dissection in intermediate- and high-risk patients. Intraprostatic and pelvic nodal [68Ga]Ga-RM2 and [18F]FCH PET-CT findings were correlated with mpMRI and histopathologic results.ResultsOf the 312 analyzed regions, 120 regions (4 to 8 lesions per patient) showed abnormal findings in the prostate gland. In a region-based analysis, overall sensitivity and specificity of [68Ga]Ga-RM2 PET-CT in the detection of primary tumor were 74% and 90%, respectively, while it was 60% and 80% for [18F]FCH PET-CT and 72% and 89% for mpMRI. Although the overall sensitivity of [68Ga]Ga-RM2 PET-CT was higher compared to that of [18F]FCH PET-CT and mpMRI, the statistical analysis showed only significant difference between [68Ga]Ga-RM2 PET-CT and [18F]FCH PET-CT in the intermediate-risk group (p = 0.01) and [68Ga]Ga-RM2 PET-CT and mpMRT in the high-risk group (p = 0.03). In the lesion-based analysis, there was no significant difference between SUVmax of [68Ga]Ga-RM2 and [18F]FCH PET-CT in the intraprostatic malignant lesions ([68Ga]Ga-RM2: mean SUVmax: 5.98 ± 4.13, median: 4.75; [18F]FCH: mean SUVmax: 6.08 ± 2.74, median: 5.5; p = 0.13).Conclusions[68Ga]Ga-RM2 showed promising PET tracer for the detection of intraprostatic PCa in a cohort of patients with different risk stratifications. However, significant differences were only found between [68Ga]Ga-RM2 PET-CT and [18F]FCH PET-CT in the intermediate-risk group and [68Ga]Ga-RM2 PET-CT and mpMRT in the high-risk group. In addition, GRP-R-based imaging seems to play a complementary role to choline-based imaging for full characterization of PCa extent and biopsy guidance in low- and intermediate-metastatic-risk PCa patients and has the potential to discriminate them from those at higher risks.Key Points• [68Ga]Ga-RM2 is a promising PET tracer with a high detection rate for intraprostatic PCa especially in intermediate-risk prostate cancer patients.• GRPr-based imaging seems to play a complementary role to choline-based or PSMA-based PET/CT imaging in selected low- and intermediate-risk PCa patients for better characterization and eventually biopsy guidance of prostate cancer disease.

An analysis of the evidence underpinning the national comprehensive cancer network practice guidelines.

This study assesses the quality and completeness of systematic reviews (SRs) included by the National Comprehensive Cancer Network (NCCN) cancer screening clinical practice guidelines (CPGs). We evaluated SRs according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR-2 (A Measurement Tool to Assess systematic Reviews). Seven NCCN CPGs were included with 109 SRs. The mean PRISMA percent completeness of included SRs was 71 % (range 0.1-1.0). The mean AMSTAR-2 percent completeness was 56 % (range 0.05-0.99). Of the 70 SRs assessed via AMSTAR-2, 42 (60 %) received a "critically low" rating, 11 (15.7 %) received "low" ratings, and 17 (24.3 %) received "moderate". None of the SRs received a "high" rating. Lack of adherence to AMSTAR-2 and PRISMA reporting standards among the SRs included is prevalent. We suggest improved reporting of SR inclusion criteria and evaluation to bolster the reporting quality of SRs underpinning CPG recommendations.

Participation of Black and Hispanic women in clinical trial evidence for NCCN preferred systemic therapies in advanced ovarian cancer

<h3>Objectives:</h3> Minority participation in clinical trials is important for expanding opportunities in access to cancer therapies and may aid in understanding racial disparities in oncology care. Prior studies have identified underrepresentation in gynecologic oncology phase I recruitment and large group trials in the United States, but minority participation specific to trials that drive current treatment recommendations remains unclear. We sought to evaluate minority participation as described in publications of curated, high quality clinical evidence for ovarian cancer therapies as identified by the National Comprehensive Cancer Network (NCCN). <h3>Methods:</h3> NCCN Clinical Practice Guidelines for Ovarian Cancer, Version 1.2020, was accessed in order to identify evidence provided for ‘preferred' primary and recurrent systemic therapies and dosing regimens in advanced epithelial ovarian cancer using explicitly listed citations. Race and ethnicity data of trial enrollment provided in publications listed as references was manually abstracted. <h3>Results:</h3> We identified 26 prospective trials including 13,887 participants, published across 5 journals: <i>New England Journal of Medicine, Lancet, Lancet Oncology, Gynecologic Oncology,</i> and <i>Journal of the National Cancer Institute.</i> All were phase II or III trials and 96% of trials were published in or more recently than 2003. Of these trials, race or ethnicity was reported in only 9 publications (35%). Of these 9 publications, there was marked language variation between trials in reporting race and ethnicity. There were 7 trials that included a description of participants as Black or African American. Of the 4,701 women who participated in these trials, 206 were Black or African American, representing approximately 4% of trial participants. There were 4 trials that included a description of participants as Hispanic. Of the 3,436 women who participated in these trials, 152 were Hispanic, representing approximately 4% of trial participants. <h3>Conclusions:</h3> Of the clinical trial evidence for preferred systemic therapies identified in the NCCN clinical practice guidelines for advanced ovarian cancer, minority participation was reported in less than half of publications and description of race and ethnicity varied between trials. Of trials that reported minority participation, Black and hispanic women represented <5% of trial participants, respectively.

Economic Model Shows That Guideline Recommended Testing of Patients with Early Symptoms of Myeloma Results in Improved Patient Outcomes and Decreased Hospital Costs

Introduction : Multiple myeloma (MM) is a hematologic cancer of the plasma cells, which are found in the bone marrow. The early symptoms of MM are often vague and non-specific, such as fatigue, bone pain and back pain. These vague symptoms lead patients to present first to their primary care physician and often delay diagnosis resulting in progressive disease [MayoClinic.org]. The median time for MM diagnosis (163 days) is longer than for most other hematologic cancers including leukemias and lymphomas [Howell et al, BMC Hematol, 2013]. Delayed diagnosis of MM is commonly associated with the development of chronic complications such as renal impairment, infections, neurological disease, bone disease and anemia [Kariyawasan et al, Q J Med, 2007]. Therefore, early detection and diagnosis of MM are essential to avoid downstream complications, and may significantly reduce the treatment costs associated with these complications. In the assessment of symptomatic patients, National Comprehensive Cancer Network (NCCN) practice guidelines recommend using three tests to maximize sensitivity and specificity: serum protein electrophoresis (SPE), serum immunofixation electrophoresis (SIFE) and serum free light chains (SFLC) [NCCN Multiple Myeloma Guidelines Version 3.2017]. However, physician compliance with these guidelines is hampered by the many different test options available and the low visibility of Myeloma on the list of possible causes for the primary care physician. In the current study, we modeled the effect of converting a hospital system over to guideline compliance in testing for Multiple Myeloma.Methods : A decision analytic model was developed to estimate the total costs and annual budget impact when using the guideline recommended panel for early diagnosis of MM patients. Using a US hospital (i.e., integrated delivery network [IDN]) model perspective, a decision algorithm was developed based on NCCN and IMWG clinical practice guidelines and further validated by clinicians [Rajkumar et al, Lancet Oncol. 2014]. Comparators include SPE alone, SPE+SFLC, SPE+UPE (urine protein electrophoresis), SPE+SIFE and SPE+SFLC+SIFE. Epidemiology estimates were from the SEER database [Surveillance, Epidemiology, and End Results (SEER) Program SEER*Stat]. Test sensitivity and specificity and downstream complication rates were based on published sources [Katzmann et al, Clin Biochem Rev, 2009 and McTaggart et al. Am J Clin Pathol, 2013]. Lab and imaging costs were collected from the CMS laboratory fee schedule and downstream complication treatment costs from the HCUP National Inpatient Sample database.Results : For an average IDN, a total of 967 patients are estimated to undergo evaluation for MM each year. Conversion from typical current practice to guideline compliance is estimated to reduce the time to MM diagnosis from 159 days to 45 days per patient (64% reduction). The number of correct MM diagnoses increases from 949 to 967 per year. Hospital laboratories would expect to invest $37,680 per year in additional diagnostic costs in order to save the hospital system a total of $74,135 annually in averted complications (24% reduction in complications) resulting from earlier diagnosis. From a cost-benefit perspective, this translates to a reduced cost/correct diagnosis of about $48 and savings per averted complication of $3,975 for the hospital system.Conclusions: Guideline recommended testing of patients with early symptoms of Multiple Myeloma can help reduce costs, improve patient outcomes and increase efficiency of care. Hematologists, as stewards of the guidelines, should help in educating primary care physicians on warning signs of MM and appropriate diagnostic tests. [Display omitted] DisclosuresWu:Celator/Jazz: Consultancy. Jensen:Celator/Jazz: Consultancy. Cyr:Celator/Jazz: Consultancy.

Trends in female representation in clinical practice guidelines (CPGs) among major cancer organizations.

11006 Background: While women representation and sex disparities in National Comprehensive Cancer Network (NCCN) and European Society of Medical Oncology (ESMO) has been studied in a limited set of CPGs, the sex representation and disparity trend over time among all NCCN and ESMO CPG panelists has not been studied. Our study evaluates the current sex disparities and female representation for all NCCN and ESMO CPGs as of 2020 and compared it to the 2010 CPGs of both organizations. Methods: The 2010 and 2020 version of NCCN and ESMO CPGs were examined from their respective websites and archives. We catalogued the number of female versus male panelist for each CPG. We discerned the sex of the panelists based on google search and the panelists’ affiliated institutional websites. Results: 60 NCCN (2020), 51 NCCN (2010), 78 ESMO (2020) and 55 ESMO (2010) CPGs inclusive of all cancers by site, detection prevention and risk reduction, supportive care, and guidelines for specific population were reviewed. NCCN 2020 CPGs had 55.5% female representation. 35 (58%) NCCN CPGs had predominant female representation (&gt;50% of the members being female) whereas 24 CPG (40%) were male predominant (&gt;50% of the members being male). Solid tumors had 24 CPGs with male predominance and hematological malignancies had 14 CPGs with female predominance. Cancers specific to women had higher proportion of female panelist. NCCN 2010 CPGs had 27.1% female representation. Both solid tumors and hematological malignancies had male predominance (82% and 75% respectively). Breast cancer screening, palliative care and older adult oncology CPGs were female predominant. ESMO 2020 had 27.8% female representation. Both solid tumors (37 CPGs) and hematological malignancies (17 CPGs) had predominant male representation (72% and 85% respectively). Breast and ovarian cancer CPGs were female predominant. ESMO 2010 had 23.2% female representation. Male representation was predominant in both solid tumors (35 CPGs) and hematological malignancies (9 CPGs). Breast, cervical and ovarian cancer CPGs were female predominant. Conclusions: Over the last decade, proportion of female panelists in NCCN CPGs has doubled with more than 50% representation among its 60 CPGs, indicating adequate representation of women. In ESMO, although there has been a significant improvement in female representation in hematological malignancies over time, it continues to have overall female underrepresentation (&lt;30%).[Table: see text]

The Role of Percutaneous Ablation in Musculoskeletal Metastases

The Role of Percutaneous Ablation in Musculoskeletal Metastases

Importance of Compliance With Guidelines for the Prevention of Varicella-Zoster Virus Reactivation in Multiple Myeloma.

The importance of compliance with National Comprehensive Cancer Network (NCCN) guidelines for preventing varicella-zoster virus reactivation (VZVr) in multiple myeloma (MM) in a clinical setting has not been well investigated. We retrospectively studied the clinical characteristics and outcomes of 118 patients with MM treated with proteasome inhibitors. Thirty-nine episodes of VZVr were observed in 37 patients (VZVr group). The proportion of prophylactic antiviral prescriptions and compliance with antiviral prophylaxis based on the NCCN Clinical Practice guidelines was 76% and 30% in the VZVr group, and 88% and 74% in the non-VZVr group, respectively. Multivariate analysis showed that compliance with the NCCN guidelines was the only independent risk factor for VZVr (p=0.0017). It is important that prophylactic antivirals are prescribed for an appropriate duration of time to prevent the reactivation of VZV in compliance with existing guidelines.

Updates and interpretations of the NCCN Clinical Practice Guidelines (2019 6th version) on gastrointestinal stromal tumor

The diagnosis and treatment of gastrointestinal stromal tumor (GIST) is getting more and more standardized. In the last two decades, due to the elucidation of molecular mechanism of tumorigenesis, as well as the effectiveness of tyrosine kinase inhibitors, GIST has become well-known as one of the most classical models of targeted therapy on solid tumors in the precision medicine era. The National Comprehensive Cancer Network (NCCN) issued the latest version of clinical practice guideline on soft tissue sarcoma in February 2020. Compared with previous versions, the new version of the guideline highlighted the treatment recommendations of avapritinib, which further promoted the precise targeted treatment of GIST.

Prognosis of limited-stage small cell lung cancer with comprehensive treatment including radical resection

BackgroundThe NCCN (National Comprehensive Cancer Network) Clinical Practice Guidelines in Oncology (NCCN guidelines) recommend radical resection for T1-2N0M0 patients with limited-stage small cell lung cancer (LS-SCLC). However, only about 5% of patients with small cell cancer (SCLC) were initially diagnosed as T1-2N0M0. The purpose of our study was to analyze and compare the effects of the comprehensive treatment including radical surgery and concurrent chemoradiotherapy on the prognosis of patients with LS-SCLC.MethodsWe comprehensively reviewed the medical data of patients with SCLC diagnosed by pathology in our hospital from January 2011 to April 2018. The Ethics Committee of West China Hospital of Sichuan University approved the study. Finally, 50 patients with good follow-up and complete medical data were selected as the surgical group (S group). According to the clinical characteristics of the patients in the S group, 102 LS-SCLC patients who received concurrent chemoradiotherapy in the same period were included in the CCRT group (concurrent chemoradiotherapy group) as the control group. Then according to the orders of the adjuvant treatments, the patients in the S group were divided into the SA group (radical surgery + adjuvant chemotherapy + adjuvant radiotherapy group, 30 cases in total) and the NS group (neoadjuvant chemotherapy + radical surgery + adjuvant chemotherapy ± adjuvant radiotherapy group, 20 cases in total) for subgroup analysis. The SPSS 23.0 software was used for statistical analysis, and the t test was used for group comparison; Kaplan-Meier was used for survival analysis. P < 0.05 demonstrates a statistically significant difference.ResultsThe median progress-free survival (PFS) in the S group (73 months) was significantly better than that in the CCRT group (10.5 months, P < 0.0001), and the median overall survival (OS) in the S group (79 months) was also significantly better than that in the CCRT group (23 months, P < 0.0001). Subgroup analysis showed that there was no significant difference between the NS group and the SA group.ConclusionsFor LS-SCLC patients, the comprehensive treatment including radical surgery (radical surgery + adjuvant chemotherapy ± adjuvant radiotherapy/neoadjuvant chemotherapy + radical surgery + adjuvant chemotherapy ± adjuvant radiotherapy)may be superior to concurrent chemoradiotherapy.

Level of evidence used in recommendations by the National Comprehensive Cancer Network (NCCN) guidelines beyond Food and Drug Administration approvals.

BackgroundA previous analysis of 113 National Comprehensive Cancer Network® (NCCN®) recommendations reported that NCCN frequently recommends beyond Food and Drug Administration (FDA)-approved indications (44 off-label recommendations) and claimed that the evidence for these recommendations was weak.MethodsIn order to determine the strength of the evidence, we carried out an in-depth re-analysis of the 44 off-label recommendations listed in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®).ResultsOf the 44 off-label recommendations, 14 were later approved by the FDA and/or are supported by randomized controlled trial (RCT) data. In addition, 13 recommendations were either very minor extrapolations from the FDA label (n = 8) or were actually on-label (n = 5). Of the 17 remaining extrapolations, 8 were for mechanism-based agents applied in rare cancers or subsets with few available treatment options (median response rate = 43%), 7 were based on non-RCT data showing significant efficacy (>50% response rates), and 2 were later removed from the NCCN Guidelines because newer therapies with better activity and/or safety became available.ConclusionOff-label drug use is a frequent component of care for patients with cancer in the United States. Our findings indicate that when the NCCN recommends beyond the FDA-approved indications, the strength of the evidence supporting such recommendations is robust, with a significant subset of these drugs later becoming FDA approved or supported by RCT. Recommendations without RCT data are often for mechanism-based drugs with high response rates in rare cancers or subsets without effective therapies.

Cells to Surgery Quiz: December 2018

Cells to Surgery Quiz: December 2018

National Comprehensive Cancer Network: Global Utilization of Clinical Oncology Guidelines

Background: The global influence and demand for clinical oncology guidelines is increasing. National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO), European Society of Medical Oncology (ESMO), and various other organizations develop clinical oncology guidelines, which are used across regions to provide evidence-based recommendations for the management of cancer.1 Aim: To identify and analyze utilization trends of clinical oncology guidelines outside the US. Methods: In 2017, NCCN distributed an electronic survey to 212,423 registered users of the NCCN Web site outside the US through a third party software. Participants were prompted to respond to the following statement “I consult the following guidelines regularly: (Select all that apply).” Options included several clinical oncology guidelines, as well as the option “I do not regularly consult clinical oncology guidelines.” The survey also included the following query: “In my opinion, the NCCN Guidelines are: (select one per row).” The survey then listed several descriptors and the respondents were asked to select strongly agree, agree, no opinion, disagree, or strongly disagree for each one. Results: NCCN received 1698 responses to the survey from oncology professionals outside of the US. Of this pool, 82% of respondents identified as physicians and 18% were other oncology professionals. Of respondents to the first query (n=1190), 89% selected the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines), 55% ESMO Clinical Practice Guidelines, 50% ASCO Guidelines, 20% National Institute for Health and Care Excellence (NICE) guidelines, 15% local, national, or other oncology guidelines, 11% Sociedad Española de Oncología Médica (SEOM), 8% Cancer Care Ontario Guidelines, 7% Multinational Association of Supportive Care in Cancer (MASCC), 6% Japanese Society of Medical Oncology Clinical Guidelines, and 6% do not regularly consult clinical oncology guidelines. In response to the second query (n=1392), more than 90% of respondents outside of the US “strongly agree” or “agree” that the NCCN Guidelines are useful in patient care decision-making, a reliable reference, up-to-date, objective and balanced, evidence-based, and helpful in clinical teaching. Conclusion: Based on data presented, NCCN Guidelines are consulted more frequently than any other clinical oncology guideline outside the US. Previous research indicates similar utilization trends. We believe, in part, healthcare professionals outside the US consult the NCCN Guidelines frequently due to the descriptors listed in the survey results. Additional research is needed to identify the synergies between the relevance of international clinical oncology guidelines and local utilization trends to better serve the needs of patients globally.

Updates and interpretation on NCCN clinical practice guidelines for gastric cancer 2017 version 5

The National Comprehensive Cancer Network (NCCN) issued the clinical practice guidelines for gastric cancer 2017 edition version 5, which has been fully updated for the treatment of gastric cancer, including systematic treatment, surgery and radiotherapy. This article review and summarize the updated NCCN clinical practice guidelines for gastric cancer in 2017 and try to interpret it. (1)Biomarkers: mismatch repair defect (dMMR) or high microsatellite instability (MSI-H), programmed death ligand 1 (PD-L1) and tumor Epstein Barr virus (EBV) status should be considered for patients with gastric cancer. (2)Treatment of advanced gastric cancer: the major update is the application of immunotherapy (Pembrolizumab, Nivolumab combined with Ipilimumab). (3)Adjuvant therapy after D2 resection and perioperative treatment: the guidelines recommended Capecitabine combined with Oxaliplatin as adjuvant therapy after radical operation, updated from category 2A to 1; although the 2017 edition of the NCCN guidelines have not yet been adopted, Docetaxel-based FLOT scheme has certain potential in adjuvant therapy for gastric cancer. (4) Radiotherapy: a more detailed definition of radiotherapy for gastric cancer in different locations, especially in high-risk lymphatic drainage areas, was updated. (5) Genetic risk assessment: the guidelines recommended genetic screening for gastric cancer, including hereditary diffuse gastric cancer (HDGC), Lynch syndrome, juvenile polyposis (JPS), Peutz-Jephers syndrome (PJS) and familial adenomatous polyposis (FAP). The NCCN guidelines continue to update based on new evidences, which is the embodiment of precision medicine in the treatment of gastric cancer. The biggest change in the 2017 gastric cancer guidelines is the updates of immunotherapy, which also suggests that the direction of the gastric cancer treatment began to turn to immunotherapy.

Abstract PD7-01: Impact of guideline concordant treatment on cost and health care utilization in early stage breast cancer patients

Abstract Introduction: National Comprehensive Cancer Network (NCCN) guideline-based treatment is increasingly recognized as a marker of high quality care. Payers are progressively limiting reimbursement for non-guideline based care as they move towards value-based cancer care. However, the impact of treatment regimen concordance with NCCN guidelines on cost and health care utilization in early stage breast cancer is unclear. Methods: This was a secondary analysis of Medicare administrative claims data from 2012-2015 for all women aged ≥65 with stage I-III breast cancer who received care within the University of Alabama at Birmingham Cancer Community Network. Concordance to NCCN Clinical Practice guidelines was assessed for treatment regimens including hormonal medications, chemotherapy, and/or HER2-targeted therapy. Costs to Medicare (reimbursements to providers for all care received) were averaged monthly from the start of cancer treatment until death or available follow-up. Health care utilization (emergency department [ED] visits and hospitalizations) was identified from the start of cancer treatment until death or available follow-up. Cost and adjusted monthly utilization rates per thousand observations and their corresponding 95% confidence intervals (CI) were estimated using linear mixed effect models and generalized linear models, respectively, using the negative binomial distribution and log link function. Results: Of 1042 patients on treatment for early stage breast cancer, 82% received a guideline concordant treatment, with 79% receiving a “preferred” treatment and 3% receiving an “other” but still on-guideline treatment. Those receiving guideline concordant treatment were more likely to be white, treated at large volume centers, have an earlier stage cancer, ER/PR positive, and HER2 negative (p&amp;lt;0.05). Among patients receiving chemotherapy (N=496), 63% of patients received guideline concordant treatment (55% “preferred”, 8% “other”). After adjusting for age, race, treatment center volume, and stage, average monthly costs after initiation of treatment for guideline concordant patients were $1464 lower compared to guideline discordant patients (95% CI $1135-$1793, p&amp;lt;.001). For guideline concordant patients, adjusted rates of ED visits per thousand observations were 41% lower at 51.3 per month (95% CI 44.0-59.8) compared to 77.9 per month (95% CI 62.6-96.9) for guideline discordant patients. Adjusted rates of hospitalizations per thousand observations were also 41% lower for guideline concordant patients at 28.2 per month (95% CI 23.5-33.8) compared to 42.7 per month (95% CI 32.9-55.5) for guideline discordant patients. Conclusions: Despite the majority of early stage breast cancer patients receiving guideline concordant care, almost one in five did not, with an even higher proportion of guideline discordance in those receiving chemotherapy. Guideline concordant treatment was significantly associated with lower costs and lower rates of health care utilization after adjusting for patient and center characteristics. The appropriateness of guideline deviation should be examined from both the patient and payer perspectives. Citation Format: Williams CP, Azuero A, Pisu M, Halilova KI, Adewakun S, Yagnik SK, Goertz H-P, Rocque GB. Impact of guideline concordant treatment on cost and health care utilization in early stage breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD7-01.

National Comprehensive Cancer Network (NCCN) risk classification in predicting biochemical recurrence after radical prostatectomy: a retrospective cohort study in Chinese prostate cancer patients.

This study aimed to assess the role of the National Comprehensive Cancer Network (NCCN) risk classification in predicting biochemical recurrence (BCR) after radical prostatectomy (RP) in Chinese prostate cancer patients. We included a consecutive cohort of 385 patients with prostate cancer who underwent RP at Fudan University Shanghai Cancer Center (Shanghai, China) from March 2011 to December 2014. Gleason grade groups were applied at analysis according to the 2014 International Society of Urological Pathology Consensus. Risk groups were stratified according to the NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer version 1, 2017. All 385 patients were divided into BCR and non-BCR groups. The clinicopathological characteristics were compared using an independent sample t-test, Chi-squared test, and Fisher's exact test. BCR-free survival was compared using the log-rank test and multivariable Cox proportional hazard analysis. During median follow-up of 48 months (range: 1–78 months), 31 (8.05%) patients experienced BCR. The BCR group had higher prostate-specific antigen level at diagnosis (46.54 ± 39.58 ng ml-1 vs 21.02 ± 21.06 ng ml−1, P = 0.001), more advanced pT stage (P = 0.002), and higher pN1 rate (P < 0.001). NCCN risk classification was a significant predictor of BCR (P = 0.0006) and BCR-free survival (P = 0.003) after RP. As NCCN risk level increased, there was a significant decreasing trend in BCR-free survival rate (Ptrend = 0.0002). This study confirmed and validated that NCCN risk classification was a significant predictor of BCR and BCR-free survival after RP.

PCN210 - Lung Cancer Management in China: Treatment Disparities that Need to be Resolved

Owing to the large smoking population and air pollution, the incidence of lung cancer is continuously increasing in China. It has adapted the National Comprehensive Cancer Network (NCCN) clinical practice guidelines in lung cancer for disease management. However, studies have suggested that there are large disparities in the treatment of lung cancer in China. The objective of this research is to identify the factors that contribute to treatment disparity in China. A literature search was conducted to retrieve NCCN and other clinical practice guidelines describing management of lung cancer patients in China. The guidelines were reviewed to assess the treatment disparities for lung cancer management in China. The NCCN China edition comprises of extensive expertise of more than 100 Chinese cancer specialists and NCCN panel experts. The country adaptation version of China has considered metabolic differences in populations, accessibility of technology, and regulatory status of health technologies in China. Treatment disparities for lung cancer exist in terms of disease staging, chemotherapy for advanced disease, and targeted therapies for advanced stage lung cancer. Further, patients from developed cities have access to more standard treatment compared with those from other regions. A study reported that 20.6% of stage I patients were over-treated and 20.1% of stage II patients were under-treated. These treatment disparities are severe as the adoption of evidence-based guideline recommended treatments are probably the best and the only way to significantly improve the treatment of lung cancer. Treatment disparities could be attributed to high treatment costs, insufficient insurance coverage, lack of oncologists and lack of awareness to advance therapies. Increased collaboration is required among different areas in China to ensure that all lung cancer patients, regardless of socioeconomic and geographic barriers, are treated with and reimbursed for standardize treatment and palliative care.

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

PurposeThe 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. MethodsThe 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. ResultsA 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. ConclusionNCCN 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.

Interpretation of 2015 NCCN clinical practice guidelines of endometrial uterine cancers

Version 2015 of the National Comprehensive Cancer Network (NCCN) Guidelines for Uterine Neoplasms uses the 2009 International Federation of Gynecology and Obstetrics(FIGO) staging system. These NCCN guidelines divide pure endometrioid cancers into three categories to delineate treatment: ⑴ disease limited to the uterus; ⑵ cervical involvement; ⑶ extrauterine disease. Surgery is recommended for medically operable patients. Continuous progestin-based therapy may be considered for highly selected patients with stage IA disease who wish to preserve their fertility. Preoperative chemotherapy can be considered if extrauterine disease is suspected. Factors that may influence the decision regarding adjuvant therapy include lymph vascular space invasion (LVSI), patient age, tumor volume, and lower uterine segment or surface cervical glandular involvement. When administering adjuvant radiotherapy, it should be initiated as soon as the vaginal cuff has healed, no later than 12 weeks after surgery. Key words: Endometrial neoplasms; Guidebooks