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Adolescent and Young Adult (AYA) Oncology, Version 2.2024, NCCN Clinical Practice Guidelines in Oncology

Smita Bhatia, Alberto S. Pappo, Melissa Acquazzino, Wendy A. Allen-Rhoades, Marie Barnett, Scott C. Borinstein, Robert Casey, Sun Choo, Rashmi Chugh, Shira Dinner, Ralph Ermoian, Douglas Fair, Noah Federman, Jeanelle Folbrecht, Shipra Gandhi, Julie Germann, Robert Goldsby, Robert Hayashi, Alex Y. Huang, Mary S. Huang, Linda A. Jacobs, Cathy Lee-Miller, Michael P. Link, John A. Livingston, Maryam Lustberg, Marcio Malogolowkin, Kevin C. Oeffinger, Christine A. Pratilas, Damon Reed, Jodi Skiles, Margaret von Mehren, Nicholas Yeager, Sarah Montgomery, and Lisa Hang

This selection from the NCCN Guidelines for Adolescent and Young Adult (AYA) Oncology focuses on considerations for the comprehensive care of AYA patients with cancer. Compared with older adults with cancer, AYA patients have unique needs regarding treatment, fertility counseling, psychosocial and behavioral issues, and supportive care services. The complete version of the NCCN Guidelines for Adolescent and Young Adult (AYA) Oncology addresses additional aspects of caring for AYA patients, including risk factors, screening, diagnosis, and survivorship.

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Being Sick Isn’t Easy

Margaret Tempero

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Changes in Prescribing Patterns in Stage III Colon Cancer

Fang-Shu Ou, Daniel J. Walden, Joseph J. Larson, Sandra Kang, Cassia R. Griswold, Benjamin E. Ueberroth, Bhamini Patel, Amber Draper, Puneet Raman, Olatunji B. Alese, Mohamad B. Sonbol, Tanios S. Bekaii-Saab, Christina S. Wu, and Daniel H. Ahn

Background: For patients with resected stage III colon cancer, 6 months of adjuvant fluoropyrimidine-based chemotherapy has been the standard of care. The IDEA collaboration aimed to evaluate whether 3 months of adjuvant chemotherapy was noninferior to 6 months. Despite failing to meet its primary endpoint, the subgroup analyses demonstrated noninferiority based on regimen and treatment duration when a risk-stratified approach was used. Patients and Methods: To evaluate the impact of the results of the IDEA collaboration, we evaluated adjuvant chemotherapy prescribing practice patterns, including planned adjuvant treatment regimen and duration from January 1, 2016, to January 31, 2021. The time period was selected to evaluate chemotherapy prescribing patterns prior to the abstract presentation of the IDEA collaboration in June 2017 and after full manuscript publication in March 2018. Results: A total of 399 patients with stage III colon cancer who received adjuvant chemotherapy were included in the analysis. A significant increasing trend for use of 3 months of adjuvant chemotherapy was observed after presentation of the IDEA abstract (P<.001). A significant change in CAPOX (capecitabine/oxaliplatin) prescribing was also observed, increasing from 14% of patients prior to presentation of the IDEA abstract to 48% after presentation (P<.001). Comparing 3 months of CAPOX with 6 months of FOLFOX (fluorouracil/leucovorin/oxaliplatin), 3 months of CAPOX use also steadily increased over time (adjusted odds ratio [aOR], 1.28; 95% CI, 1.20–1.37; P<.001). Among subgroups of interest, no differences in adoption of CAPOX were observed. The adoption of 3 months of CAPOX was similar in patients with low-risk cancer (aOR, 1.27; 95% CI, 1.17–1.37) and those with high-risk cancer (aOR, 1.31; 95% CI, 1.16–1.47). Conclusions: Despite the IDEA collaboration failing to demonstrate noninferiority of 3 months’ duration of adjuvant therapy compared with 6 months, the findings have influenced practice prescribing patterns, favoring CAPOX and a shorter duration of planned adjuvant treatment.

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Compound Kushen Injection Reduces Severe Toxicity and Symptom Burden Associated With Curative Radiotherapy in Patients With Lung Cancer

Jie Liu, Qingxi Yu, Xin Shelley Wang, Qiuling Shi, Jun Wang, Fan Wang, Simeng Ren, Jiayue Jin, Baojin Han, Wenzheng Zhang, Xueyao Su, Shuanghu Yuan, and Hongsheng Lin

Background: Radiotherapy (RT) causes adverse events for which there are no effective treatments. This study investigated the clinical benefits of compound Kushen injection (CKI) in managing radiation injury in patients with lung cancer. Methods: A multicenter, open-label, randomized clinical trial randomly assigned patients with lung cancer to receive either CKI (20 mL/d for at least 4 weeks) integrated with curative RT (RT + CKI group; n=130) or RT alone (control group; n=130). The primary outcome was the incidence of grade ≥2 radiation-induced lung injury (RILI) in the lungs, esophagus, or heart. Secondary outcomes included patient-reported symptoms, quality of life, objective response rate (ORR), and toxic effects. Results: During the 16-week trial, the RT + CKI group had a significantly lower incidence of grade ≥2 RT-related injury than the control group (12.3% [n=16] vs 23.1% [n=30]; P=.02). Compared with the control group, the RT + CKI group experienced a significant decrease in moderate-to-severe symptoms of fatigue, cough, and pain (P<.001 for the treatment and time interaction term); significantly less physical symptom interference (P=.01); and significantly better quality of life by the end of the trial (P<.05). No statistically significant difference in ORR was found. Adverse reactions associated with CKI were rare. Conclusions: This study demonstrated low toxicity of CKI and its effectiveness in patients with lung cancer in reducing the incidence of grade ≥2 RILI and symptom burden, improving patients' quality of life.

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Ensuring Diversity and Inclusion in Clinical Development by Leveraging Community Oncology Centers

Joshua Richter, Stephen J. Noga, and Robert Rifkin

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Hematologic Malignancy: Who Cares in the End? A Retrospective Cohort Study of Markers of Quality End-of-Life Care

Briony Shaw, Catriona Parker, Stephen Opat, Jake Shortt, and Peter Poon

Background: Early palliative care is increasingly used in solid organ malignancy but is less established in patients with hematologic malignancy. Disease-related factors increase the demand for hospitalization, treatment, and supportive care in patients with hematologic malignancy. The terminal phase of illness in patients with hematologic malignancy can be difficult to predict, resulting in complexities in establishing a standard for quality end-of-life care. Methods: This is a retrospective single-center cohort study of adult patients with hematologic malignancy who died between October 2019 and July 2022. Patients were identified, and disease characteristics, therapy, and outcomes were extracted from medical records. Descriptive statistics are reported and univariate analyses were performed across a range of factors to assess for associations. Results: A total of 229 patients were identified, with a median age of 77 years and 35% female. In the final 30 days of life, 65% presented to the emergency department, 22% had an ICU admission, 22% had an invasive procedure, 48% received cytotoxic therapy, 61% received a RBC transfusion, and 46% received a platelet transfusion. Use of intensive chemotherapy was particularly associated with hospitalization and ICU admission. A total of 74% referred to palliative care, with a median time from referral to death of 13 days. Of these patients, one-third were referred within the last 5 days of life. In terms of place of death, 54% died in the acute hospital setting and 30% in hospice, with a median hospice length of stay of 4 days. Conclusions: These findings highlight the need for further research into quality indicators for end of life in hematologic malignancy and earlier integration of specialist supportive and palliative care in both inpatient and outpatient settings.

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Highlights of the NCCN Oncology Research Program

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NCCN Guidelines® Insights: Survivorship, Version 1.2023

Featured Updates to the NCCN Guidelines

Tara Sanft, Andrew Day, Shannon Ansbaugh, Saro Armenian, K. Scott Baker, Tara Ballinger, Wendy Demark-Wahnefried, Kristin Dickinson, Nathan Paul Fairman, Josephine Felciano, Tessa Faye Flores, Debra L. Friedman, Nicolette M. Gabel, Mindy Goldman, Norah Lynn Henry, Christine Hill-Kayser, Melissa Hudson, Divya Koura, Kimberly Lee, Allison L. McDonough, Michelle Melisko, Kathi Mooney, Halle C.F. Moore, Natalie Moryl, Heather Neuman, Tracey O’Connor, Linda Overholser, Electra D. Paskett, Chirayu Patel, Lindsay Peterson, William Pirl, Andrea Porpiglia, M. Alma Rodriguez, Lidia Schapira, Anna L. Schwartz, Sophia Smith, Amye Tevaarwerk, Eric Yang, Phyllis Zee, Nicole R. McMillian, and Deborah A. Freedman-Cass

The NCCN Guidelines for Survivorship are intended to help healthcare professionals address the complex and varied needs of cancer survivors. The NCCN Guidelines provide screening, evaluation, and treatment recommendations for psychosocial and physical problems resulting from adult-onset cancer and its treatment; recommendations to help promote healthy behaviors and immunizations in survivors; and a framework for care coordination. These NCCN Guidelines Insights summarize recent guideline updates and panel discussions pertaining to sleep disorders, fatigue, and cognitive function in cancer survivors.

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Pancreatitis and Hyperlipasemia in the Setting of Immune Checkpoint Inhibitor Therapy

Matthew J. Townsend, Mofei Liu, Anita Giobbie-Hurder, Jordan S. Sack, Nicole R. LeBoeuf, F. Stephen Hodi, Julia McNabb-Baltar, and Shilpa Grover

Background: Immune checkpoint inhibitor–induced pancreatic injury (ICI-PI) ranges from asymptomatic hyperlipasemia to symptomatic acute pancreatitis (AP). The proportion of pancreatic injury while receiving ICIs that is attributable to therapy remains unclear. We evaluated the etiology of hyperlipasemia in patients receiving ICIs, and the clinical characteristics, management, and outcomes of ICI-PI. Patients and Methods: We assessed 6,450 consecutive adult patients with cancer who received ICI doses between 2011 and 2019, 364 of whom had at least 1 instance of elevated serum lipase after ICI initiation and were included in our trial. Primary outcomes were the development of ICI-PI and ICI–induced acute pancreatitis (ICI-AP). Results: Pancreatic injury was attributable to ICI use in 105 individuals (29% of those with hyperlipasemia; 1.6% overall). Of 27 patients with ICI-AP, 4 (15%) presented asymptomatically with hyperlipasemia and pancreatic inflammation on imaging. In multivariable regression, the presence of other immune-related adverse events was positively associated with ICI-AP (≥2 events: odds ratio, 5.43; 95% CI, 1.47–26.03). Compared with patients with other ICI-PI, those with ICI-AP more frequently required steroids (74% vs 4%), intravenous fluids (85% vs 10%), hospitalization (89% vs 9%), and permanent cessation of ICIs due to pancreatic injury (70% vs 3%), and less frequently continued therapy uninterrupted (0% vs 40%) (P<.01 for all). Of the 105 patients, 3 (3%) developed exocrine insufficiency and 9 (9%) developed endocrine insufficiency, which were concentrated among those with ICI-AP. Conclusions: A minority of occurrences of pancreatitis and hyperlipasemia in patients receiving ICIs are due to these therapies, supporting NCCN recommendations to exclude alternative etiologies. Because a notable proportion of patients with ICI-AP were asymptomatic but warranted treatment per current guidelines, abdominal imaging is diagnostically valuable in those with significant hyperlipasemia. Patients with ICI-AP should be monitored for exocrine pancreatic insufficiency. Many with hyperlipasemia who do not meet the criteria for AP can continue therapy uninterrupted.