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Harold J. Burstein

“There is no greater threat to the integrity of the clinical research enterprise than the appearance or reality of a conflict of interest—be it financial, academic, or scientific.”1 This is from the American Society for Clinical Oncology (ASCO) guideline on oversight of clinical research, and it would seem to apply also for the NCCN guidelines, which are created by experts from leading academic oncology centers and built on results of research and clinical judgment. Public scrutiny of conflict of interest in medicine is at an all-time high, fueled by expanding concerns over relationships between industry and physicians and ignited by reports of abuses. Ethicists note that conflict of interest rules are designed to maintain the “integrity of professional judgment” and to “minimize conditions” that would cause others to question that judgment.2 Rules center on disclosing, managing, and, when necessary, prohibiting conflicts. Yet research studies have shown tremendously variable practices, including how conflicts are classified and reported, monetary values permitted, and the management of potential conflicts.3,4 Greater transparency in conflict of interest management is important. In response to these evolving concerns, NCCN recently revised its conflict of interest practices (http://www.nccn. org/about/disclosure.asp). Instead of reporting the entire panel membership conflicts as an aggregate statement, NCCN has begun reporting individual disclosures for each panel member. Other oncology organizations, such as ASCO, are also revising conflict of interest policies for individuals on guideline committees. Furthermore, these steps are only part of a growing roster of probable changes in how potential conflicts are reported and...
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Harold J. Burstein

A unique hallmark of comprehensive cancer care is treatment delivered in well-organized teams. Most comprehensive cancer centers organize care around multidisciplinary provider teams that center on the disease rather than the training or professional background of the providers. Most oncology patients can identify multiple clinicians who are part of their cancer care team. Most guidelines in oncology, and certainly the NCCN Clinical Practice Guidelines in Oncology, invariably describe integrated, multidisciplinary management. The number of sub-specialists involved in caring for a single patient can be legion: surgical, radiation, and medical oncologists; radiologists; pathologists; pain or palliative care specialists; geneticists; psychologists, social workers, and counselors; oncology-specialized treatment and symptom-control nurses, nurse practitioners, and physician assistants. A patient with newly diagnosed cancer who is embarking on a multidisciplinary treatment program might encounter literally dozens of health care providers—each with his or her own business card, email address, and pager number—who will weigh in on the treatment plan and goals. Further, all these clinicians must communicate with each other and work together to deliver the type of seamless care that patients deserve. Sometimes the entire cancer care team works in the same building at a single institution; other times, the members may be joined in a loose confederation or work at entirely different cancer clinics. This brings up many questions. How are teams created and sustained? How is com-munication facilitated and enhanced? Although easily recognized as an important goal incancer care, the fully integrated team of cancer specialists is not an easy creation. Medical...
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Harold J. Burstein

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Harold J. Burstein

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Harold J. Burstein

JNCCN – The Journal of the National Comprehensive Cancer Network is committed to publishing the world's most authoritative and comprehensive cancer treatment guidelines, the NCCN Clinical Practice Guidelines in Oncology. These invaluable, evolving, state-of-the-art documents articulate best known treatment based on evidence from the literature and collected wisdom of experts. To enhance its value, JNCCN also publishes timely reviews and commentaries that expand on important themes or emerging practices. However, guidelines are not the end of determining quality health care. How are guidelines interpreted and applied? What trends emerge? To what extent should and do cost considerations affect both recommendations and treatments? What important benchmarks should define our best practices? In a vast and varied world, what can different cultures and perspectives teach us about optimal care? How can societies with fewer resources access appropriate innovations, and what lessons can we learn from medical care in places without the resources available here? Although these questions are not unique to cancer care, they are particularly important in oncology. Cancer is a global health burden and a growing problem. Cancer care is also a high stakes game—the pairing of lethal disease and toxic treatment demands high-quality decisions executed correctly. Cancer treatments are expensive, and cancer care is complicated. For all these reasons, JNCCN is issuing a call for papers on excellence in cancer care, from both academic and community perspectives. We are particularly seeking original research and insightful commentary on the best ways to use resources and improve outcomes for patients. Examples of...
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Harold J. Burstein

Friday, 4:36 pm—ASCO is huge. Nearly official estimates can be found in a weekly newsletter, Farecast, distributed to taxi drivers in Orlando, which estimates 30,000 ASCO attendees at the Orange County Convention Center. That seems large, but perspective is also important: next week is a beauty products show for which they expect 41,000 attendees. Apparently, that crowd is more likely to use cabs. Saturday, 9:36 am—Major changes reflect global trends. First, exhibitors no longer hand out “freebies”: no more pens, note pads, key chains, squishy balls, calendars, paper dispensers, or pocket flashlights with company logos. The absence of the usual enormous, brightly colored tote bags changes the complexion of the whole crowd. Mercifully, one can still get a slug of espresso and a small cup of frozen yogurt, gratis. Second, the fear of swine flu has prompted a new must-have accessory: small bottles of hand sanitizer, free for the taking from big tubs in the registration hall. Saturday, 5:49 pm—As day 2 comes to an end, the chattering masses are exhilarating, in part because of the large international contingent. Oncology is truly a worldwide enterprise, and doctors, researchers, and pharmaceutical representatives are here from all over the globe. The reach of meetings like this is exciting. New findings will radiate out, and I realize that patients all over the world might have their treatments, and thus their lives, affected by what is presented here. Sunday, 11:02 am—I visit the booth of Cold Spring Publishing, JNCCN's new publisher, where computers are...
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Harold J. Burstein

In November 2008, the journal Nature published 2 extraordinary articles revealing the potential utility for genomics. Each contribution was a gargantuan task and technical tour de force. One article described the reconstruction of the woolly mammoth genome, using ancient DNA salvaged from the hair of an extinct mammoth frozen in permafrost for over 100,000 years. The other described the first complete sequencing of a cancer cell—a cytogenetically “normal” acute leukemia cell. Each of these contributions was reported on by major media outlets, and these reports led to grandiose, futuristic predictions of what to make of this vast if repetitive genetic information. In the case of the mammoth, the frequently voiced hope was that the DNA sequence could lead to regeneration of a living woolly mammoth—presumably for research purposes and not to serve as the ultimate fur coat. For the cancer cell, the hope was that the full coding DNA sequence of the malignant cell could tell clinicians how to uniquely treat each patient with cancer. For now, both those dreams are science fiction, but the latter scheme seems far more approachable than the former. In probing more than 2.5 million single nucleotide variants, investigators found more than 97% concordance with the “normal” genome of the same individual, based on sequencing DNA from healthy skin. In fact, leukemic cells had acquired mutations in only 10 named genes across the human genome, a new standard for needle-in-the-haystack searches. Intriguingly, 2 of the mutated genes were FLT3 and NPM1, loci implicated in previous...
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Harold J. Burstein

This year marks the sixth volume of JNCCN—The Journal of the National Comprehensive Cancer Network. What began as a quarterly publication has expanded to 10 issues per year with multiple additional supplements, with a subscription base of more than 20,000 oncologists and other health care practitioners per issue. JNCCN has been accepted for indexing in PubMed/MEDLINE since 2005, making the NCCN guidelines and original articles published in it available worldwide in the leading databases of medical research. I am honored to serve as the next editor-in-chief of JNCCN. The NCCN includes 21 of the leading cancer centers in the United States, bringing together the multidisciplinary expertise of all types of cancer specialists. The “jewels in the crown” are the NCCN Clinical Practice Guidelines in Oncology, the most comprehensive, up-to-date guides for managing cancers of all types. These guidelines are authored by panels composed of experts from all cancer-related disciplines—pathologists, radiologists, surgeons, medical oncologists, radiation oncologists, cancer survivors, and other clinicians focused on cancer care and prevention. The breadth, depth, and timeliness of the NCCN guidelines, along with their origin from the outstanding cancer clinics in this country, give them unique authority in defining treatment standards. JNCCN is committed to publishing these essential and scholarly cancer care documents and seeks additionally to create “value added” for the reader interested in understanding the evolving nature of cancer treatment. In the issues to come, we hope to expand the commentary that accompanies the guidelines, highlighting areas of disagreement or controversy or pointing to...