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Early-stage Hodgkin lymphoma is a highly curable malignancy, but controversies surrounding treatment recommendations persist due to the sheer number of treatment choices available, as well as the effort to balance risk versus benefit for each individual patient. The gold standard for treatment has evolved over the years. Currently, in the PET era, fine-tuning therapy approaches is largely focused on avoiding giving too much therapy to patients with a negative interim PET and too little therapy to those with a positive interim PET. Careful patient selection for therapy has become increasingly important, as patient risk factors for early-stage disease are variably defined by German Hodgkin Study Group, EORTC, and NCCN criteria.

The decision of when to start treatment for patients with chronic lymphocytic leukemia (CLL) has not markedly changed; it is triggered by parameters of active disease, such as progressive symptoms or progressive cytopenias related to bone marrow compromise from disease. How to treat patients with CLL has become less complicated, given the growing list of options for CLL, and generally depends on the patient's age, presence of comorbidities, and risk factors (such as chromosome 17 or 11 deletion). During his presentation at the NCCN 20th Annual Conference, Dr. William Wierda focused attention on many of the new kids on the therapeutic block for CLL—the CD20 monoclonal antibodies obinutuzumab and ofatumumab, the BTK inhibitor ibrutinib, the PI3K inhibitor idelalisib, and the BCL-2 inhibitor venetoclax—and reviewed some of the clinical data supporting the use of these agents in different patient populations with CLL.

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer and the fifth most common cause of cancer mortality in women in the United States. Fewer than 40% of women with ovarian cancer are cured, and 70% of patients present with advanced disease; because of the location of the ovaries, ovarian cancer has been difficult to diagnose at earlier stages. Epidemiologic studies have identified risk factors, including family history. The NCCN guidelines discuss epithelial ovarian cancer as well as less common ovarian histopathologies, including germ cell neoplasms, carcinosarcomas (malignant mixed Müllerian tumors of the ovary), and ovarian stromal tumors. For 2008, updates include the addition of platinum-based combination therapy as a possible treatment modality for recurrence and a listing of preferred agents for acceptable recurrence modalities. New information was also added to the section on clinical presentation.

For the most recent version of the guidelines, please visit NCCN.org

Venous thromboembolism (VTE) is a common, life-threatening condition in patients with cancer, which includes both deep venous thrombosis (DVT) and pulmonary embolism. The occurrence of VTE has been reported to increase the likelihood of death for cancer patients by 2- to 8-fold. Pathophysiologic explanations for VTE in cancer include known hypercoagulability, vessel wall damage, and vessel stasis from direct compression, and the incidence of VTE in cancer is increased by additional risks factors. The NCCN guidelines specifically outline strategies to prevent and treat VTE in adult cancer patients. These guidelines are characterized by evaluations of the therapeutic advantages of pharmacologic anticoagulation measures based on both perceived risk for bleeding (i.e., contraindications to anticoagulation) and cancer status. Important updates for 2008 include new work-up recommendations and changes in the recommendations for outpatient prophylaxis and diagnosis and for treatment of heparin-induced thrombocytopenia.

For the most recent version of the guidelines, please visit NCCN.org

An estimated 11,150 new cases of cervical cancer will be diagnosed in the United States in 2007; 3670 deaths are expected from the disease. Although cervical cancer rates are decreasing among women in the United States, it remains a major world health problem. It is the third most common cancer in women worldwide, with 78% of cases occurring in developing countries. Because persistent human papillomavirus (HPV) infection is considered the most important factor contributing to the development of cervical cancer, immunization against HPV is expected to prevent some cancer. The NCCN Clinical Practice Guidelines in Oncology discuss this and other epidemiologic risk factors, as well as treatment options.

For the most recent version of the guidelines, please visit NCCN.org

Upper gastrointestinal (GI) tract cancers originating in the esophagus, gastroesophageal (GE) junctions, and stomach constitute a major health problem worldwide; esophageal cancer is the eighth most common cancer worldwide. An estimated 16,470 new cases of and 14,280 deaths from esophageal cancer will occur in the United States in 2008. Risk factors associated with development of esophageal cancer include age, male gender, Caucasian race, high body mass index, Barrett's esophagus, and history of gastroesophageal reflux disease. Important updates for the 2009 guidelines include a new page on “Principles of Best Supportive Care” that gives specific recommendations for esophageal cancer best supportive care throughout the guidelines.

To view the NCCN Clinical Practice Guidelines in Oncology on Gastric Cancers, please visit the NCCN Web site at www.nccn.org.

For the most recent version of the guidelines, please visit NCCN.org

Infectious diseases are important causes of morbidity and mortality in patients with cancer. In certain instances, the malignancy itself can predispose patients to severe or recurrent infections. Neutropenia has been recognized for many decades as a major risk factor, and effective strategies to anticipate, prevent, and manage infectious complications in patients with cancer experiencing neutropenia have led to improved outcomes. Reflecting the heterogeneity of immunocompromised conditions in patients with cancer and the spectrum of pathogens to which they are susceptible, NCCN expanded the scope of the Fever and Neutropenia Panel in 2007 to create guidelines on Prevention and Treatment of Cancer-Related Infections. These guidelines, newly updated for 2008, characterize major categories of immunologic deficits in persons with cancer and the major pathogens to which they are susceptible.

For the most recent version of the guidelines, please visit NCCN.org

The role of radiotherapy in treating local and regional disease in patients with clinically localized Merkel cell carcinoma remains controversial. Given the lack of randomized evidence and patient and treatment heterogeneity in published retrospective series, sound clinical judgment is required to assess individual patient risk factors. Although many single-institution series have shown that adjuvant radiation to the primary tumor site decreases the risk for local and regional failure, evidence is emerging that there is a cohort of patients at relatively low risk for local recurrence after wide local excision alone. Node dissection, radiotherapy, and combined modality treatment may all play a role in managing occult or clinically evident nodal disease, depending on the anatomic location of draining lymphatics and the extent of microscopic or macroscopic disease. For select patients, primary radiotherapy is a reasonable option with a low risk for local or regional recurrence.

Lung cancer is the leading cause of cancer death in both men and women in the United States. An estimated 171,900 new cases (91,800 in men, 80,100 in women) of lung cancer will be diagnosed in 2003, and 157,200 deaths (88,400 in men, 68,800 in women) will occur due to the disease. Only 14% of all lung cancer patients will be alive 5 years or more after diagnosis. The primary risk factor for lung cancer is smoking, which accounts for over 85% of all lung cancer-related deaths. The guidelines discuss diagnosis, staging, therapy, and surveillance for non-small cell lung cancer.

For the most recent version of the guidelines, please visit NCCN.org

An estimated 33,370 people will die of pancreatic cancer in the United States in 2007, making it the fourth most common cause of cancer-related death among men in the United States. Although incidence is roughly equal among men and women, African Americans appear to have a higher incidence of pancreatic cancer than white Americans. The NCCN Pancreatic Adenocarcinoma Guidelines discuss risk factors, diagnosis and staging, and treatment through palliative care or surveillance for patients with tumors of the exocrine pancreas. Overall, in view of the poor outcome of patients with all stages of pancreatic cancer, the NCCN panel recommends that investigational options be considered in all phases of disease management. Specific palliative measures are recommended for patients with advanced pancreatic adenocarcinoma characterized by biliary or gastric obstruction, severe abdominal pain, or other tumor-associated manifestations of the disease.

For the most recent version of the guidelines, please visit NCCN.org