Several advances in diagnosis and treatment of cutaneous melanoma were discussed at the NCCN 2021 Virtual Annual Conference. First, advances in immunotherapies and targeted agents have enhanced the role of systemic therapies in the up-front management of brain metastases in melanoma while improving survival. With dual-agent immune checkpoint inhibitors, more than half of patients with asymptomatic brain metastases that are not in high-risk anatomic areas of the brain respond to treatment, and these responses appear to be durable, sparing many patients from neurosurgery and/or stereotactic radiosurgery. In addition, molecular tests increasingly have implications for clinical decision-making in later-stage disease. The most important genetic mutation in melanoma is the BRAF V600 mutation, which can be found in approximately 40% to 50% of cutaneous melanomas.
Presenters: Douglas B. Johnson, Susan M. Swetter, April K.S. Salama, and Evan Wuthrick
Presenters: Crystal S. Denlinger, Kristina A. Matkowskyj, and Mary F. Mulcahy
For the treatment of gastric and esophageal cancers, several pivotal trials—especially those evaluating immune checkpoint inhibitors (ICIs)—have altered the treatment landscape and led to changes in the NCCN Guidelines. In addition to pembrolizumab and nivolumab, new treatment options include trastuzumab-deruxtecan (T-DXd), ramucirumab, and trifluridine/tipiracil. These agents convey varying degrees of benefit depending on treatment line, PD-L1 expression, HER2 expression, and tumor histology. Recently, ICIs have been incorporated into the first-line treatment of HER2-negative advanced esophageal, gastroesophageal junction (GEJ), and gastric cancers, in addition to second-line treatment of advanced esophageal and GEJ cancer of squamous histology. T-DXd is another new second-line option for HER2-positive esophageal, GEJ, and gastric adenocarcinomas. ICIs are now moving into the adjuvant setting as well, and a new recommendation is nivolumab use after preoperative chemoradiation and surgery in patients who have residual disease identified at the time of their R0 resections.
Presenter: Amye J. Tevaarwerk
Work limitations due to health problems can range from mild or transient limitations to persistent, long‐term dysfunction and can lead to employment instability, underemployment, and even loss of employment. In fact, compared with a healthy matched control population, cancer survivors are 1.37 times more likely to be unemployed. Because patients with metastatic disease are particularly vulnerable, proactive discussion regarding the potential impact of treatment on employment and work outcomes may be beneficial. However, employment and financial toxicity are not topics that clinicians are necessarily trained to address. Financial counselors or patient navigators may be better able to offer a personalized approach and help survivors navigate the complex resources that are involved. Additional research into cancer‐related work outcomes is needed.
Presenters: James E. Bachman, Kim Slusser, Thomas K. Varghese, Andrew Wagner, and moderated by Timothy Kubal
A panel of experts in healthcare administration and delivery convened virtually during the NCCN 2021 Virtual Annual Conference to discuss the effects of the pandemic on cancer care and what the future may hold. The discussion ranged from the effects of the pandemic on screening and the implications of missing early cancers to the challenges of telemedicine, the future delivery of more in-home services, and burnout among healthcare workers as hospitals and cancer centers work to rebuild for the future.
Presenters: Shonta Chambers, Elizabeth Harrington, Lisa A. Lacasse, Robert Winn, and moderated by Alyssa A. Schatz
Research shows that racial disparities exist in the delivery of guideline-adherent cancer care, and that non-White patients are less likely to receive guideline-concordant care than White patients, leading to worse health outcomes. However, these disparities are not often addressed. The Elevating Cancer Equity initiative aims to address these disparities through policy-change recommendations developed by a working group and informed by data from patients/caregivers and oncologists. The hope is that the results of these surveys and the resultant recommendations will be a step toward cancer care equity in the United States.
Presenters: Lillian R. Kreppel, Shivan J. Mehta, Mark H. Sawyer, Edward L. Trimble, Susan T. Vadaparampil, and moderated by Wui-Jin Koh
Infection with HPV is responsible for 5% of cancers, most of which are preventable with vaccination. Unfortunately, although vaccination rates are increasing in the United States, many adolescents remain unvaccinated due to a multifactorial set of barriers that are cultural, psychosocial, structural, and financial. At this Keynote session at the NCCN 2021 Virtual Annual Conference, a selection of expert panelists discussed efforts to improve vaccination rates.
Presenter: Sandy Srinivas
Notable developments in the management of metastatic castration-resistant prostate cancer (mCRPC) include newer, more sophisticated imaging methods based on prostate-specific membrane antigen (PSMA) PET and development of radionuclide ligands for use with this modality. In the therapeutic area, PSMA PET–guided therapeutics are under study, and PARP inhibitors are being used to treat patients with gene alterations directly or indirectly involved with the homologous recombination repair pathway. Cabazitaxel has emerged as an effective third-line option for patients treated with prior novel hormonal agents and/or prior docetaxel. As investigators learn more about sequencing therapies for mCRPC, previous exposure is an important consideration for choice of treatment at disease progression.
Presenter: Robert W. Carlson
Presenter: Arlene O. Siefker-Radtke
The advent of immune checkpoint inhibitors (ICIs) has changed the game in cancer immunotherapy, specifically in the treatment of urothelial bladder cancer. Several clinical trials combining chemotherapy with ICIs have resulted in approvals from the FDA and subsequent revisions within the NCCN Guidelines. The current NCCN Guidelines for Bladder Cancer reflect the most up-to-date, evidence-based data relating to the evaluation and management of urothelial bladder cancer. ICIs have been incorporated into the guidelines as maintenance therapy in response to chemotherapy, sequencing after disease progression from frontline chemotherapy, and for the treatment of non–muscle-invasive bladder cancer.
Presenter: Robin Kate Kelley
Multiple systemic therapy options now exist for unresectable and metastatic hepatocellular carcinoma (HCC). Atezolizumab + bevacizumab is the preferred first-line regimen, and although many second-line treatment options have recently been added to the NCCN Guidelines, none have been studied after atezolizumab + bevacizumab (all post-sorafenib), and therefore optimal sequence has yet to be established. Multiple new combination regimens with immune checkpoint inhibitors are also being studied in advanced-stage HCC. In biliary tract cancer (BTC), gemcitabine + cisplatin remains the preferred first-line regimen. FOLFOX is the preferred regimen in the second line. Multiple targeted therapy options are now available in second-line BTC for patients with tumors harboring specific mutations, and these therapeutic targets may guide future treatment sequence and combinations for BTCs.