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David S. Ettinger, Michael Kuettel, Jennifer Malin, Joan S. McClure, Mary Lou Smith, Andrew D. Zelenetz and F. Marc Stewart

Much has changed in the treatment of cancer since the first NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) were rolled out for 8 different tumor types in November 1996. NCCN Guidelines now include involved algorithms often containing multiple treatment alternatives and detailed pathways of care that depend on more-specific patient characteristics and molecular tumor diagnostics. With 47 different individual NCCN panels, all members of the cancer care team are now better informed than ever to guide patients through the often complex decision-making required to improve the odds of successful outcomes. At the NCCN 20th Annual Conference, a distinguished panel assembled to take a closer look at these invaluable clinical practice guidelines, first glancing backward to how it all started and then forward to explore the key ingredients of trustworthy guidelines.

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David S. Ettinger, Mark Agulnik, Justin M. M. Cates, Mihaela Cristea, Crystal S. Denlinger, Keith D. Eaton, Panagiotis M. Fidias, David Gierada, Jon P. Gockerman, Charles R. Handorf, Renuka Iyer, Renato Lenzi, John Phay, Asif Rashid, Leonard Saltz, Lawrence N. Shulman, Jeffrey B. Smerage, Gauri R. Varadhachary, Jonathan S. Zager and Weining (Ken) Zhen

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Carrie Zornosa, Jonathan L. Vandergrift, Gregory P. Kalemkerian, David S. Ettinger, Michael S. Rabin, Mary Reid, Gregory A. Otterson, Marianna Koczywas, Thomas A. D'Amico, Joyce C. Niland, Rizvan Mamet and Katherine M. Pisters

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) allow many systemic therapy options for patients with metastatic non–small cell lung cancer (NSCLC). This analysis uses the NCCN NSCLC Outcomes Database to report on first-line therapy practice patterns and concordance with NCCN Guidelines. The analysis was limited to patients diagnosed with metastatic NSCLC between September 2006 and November 2009 at 1 of 8 participating NCCN Member Institutions. Patient characteristics, regimens used, and guidelines concordance were analyzed. Institutional variation and changes in practice over time were also measured. A total of 1717 patients were included in the analysis. Of these, 1375 (80%) were treated with systemic therapy, most often in the form of a carboplatin-based doublet (51%) or carboplatin-based doublet with targeted therapy (17%). Overall, 76% of patients received care that was concordant with NCCN Guidelines. Among patients with good performance status (n = 167), the most common reasons for not receiving first-line therapy were that therapy was not recommended (39%) or death occurred before treatment (33%). The most common reason for receiving nonconcordant drug therapy was the administration of pemetrexed or erlotinib before its incorporation into the NCCN Guidelines for first-line therapy (53%). Most patients in this cohort received care that was concordant with NCCN Guidelines. The NSCLC Outcomes Database is a valuable resource for evaluating practice patterns and concordance with NCCN Guidelines among patients with NSCLC.

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David S. Ettinger, Debra K. Armstrong, Sally Barbour, Michael J. Berger, Philip J. Bierman, Bob Bradbury, Georgianna Ellis, Steve Kirkegaard, Dwight D. Kloth, Mark G. Kris, Dean Lim, Michael Anne Markiewicz, Lida Nabati, Carli Nesheiwat, Hope S. Rugo, Steven M. Sorscher, Lisa Stucky-Marshal, Barbara Todaro and Susan Urba

Antiemesis Clinical Practice Guidelines in Oncology NCCN Categories of Evidence and Consensus Category 1: The recommendation is based on high-level evidence (e.g., randomized controlled trials) and there is uniform NCCN consensus. Category 2A: The recommendation is based on lowerlevel evidence and there is uniform NCCN consensus. Category 2B: The recommendation is based on lowerlevel evidence and there is nonuniform NCCN consensus (but no major disagreement). Category 3: The recommendation is based on any level of evidence but reflects major disagreement. All recommendations are category 2A unless otherwise noted. Clinical trials: The NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Overview Chemotherapy-induced vomiting (emesis) and nausea can significantly affect a patient's quality of life, leading to poor compliance with further chemotherapy treatment. Nausea and vomiting can also result in metabolic imbalances, degeneration of self-care and functional ability, nutrient depletion, anorexia, decline of performance and mental status, wound dehiscence, esophageal tears, and withdrawal from potentially useful or curative anticancer treatment.1–4 The incidence and severity of nausea and/or vomiting in patients undergoing chemotherapy are affected by numerous factors, including 1) the specific chemotherapeutic agents used, 2) dosage of the agents, 3) schedule and route of administration of the agents, and 4) individual patient variability (e.g., age, sex, prior chemotherapy, history of alcohol use). Approximately 70% to 80% of all patients undergoing chemotherapy experience nausea and/or vomiting,5,6 whereas 10% to 44% experience anticipatory nausea and/or vomiting;7–10 patients often experience more...
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Razelle Kurzrock, A. Dimitrios Colevas, Anthony Olszanski, Wallace Akerley, Carlos L. Arteaga, William E. Carson III, Jeffrey W. Clark, John F. DiPersio, David S. Ettinger, Robert J. Morgan Jr, Lee S. Schwartzberg, Alan P. Venook, Christopher D. Gocke, Jonathan Tait and F. Marc Stewart

Background: With advances such as next-generation sequencing (NGS) increasing understanding of the basis of cancer and its response to treatment, NCCN believes it is important to understand how molecular profiling/diagnostic testing is being performed and used at NCCN Member Institutions and their community affiliates. Methods: The NCCN Oncology Research Program's Investigator Steering Committee and the NCCN Best Practices Committee gathered baseline information on the use of cancer-related molecular testing at NCCN Member Institutions and community members of the NCCN Affiliate Research Consortium through 2 separate surveys distributed in December 2013 and September 2014, respectively. Results: A total of 24 NCCN Member Institutions and 8 affiliate sites provided quantitative and qualitative data. In the context of these surveys, “molecular profiling/diagnostics” was defined as a panel of at least 10 genes examined as a diagnostic DNA test in a Clinical Laboratory Improvement Amendments (CLIA)–certified laboratory. Conclusions: Results indicated that molecular profiling/diagnostics are used at 100% of survey respondents' institutions to make patient care decisions. However, challenges relating to reimbursement, lack of data regarding actionable targets and targeted therapies, and access to drugs on or off clinical trials were cited as barriers to integration of molecular profiling into patient care. Frameworks for using molecular diagnostic results based on levels of evidence, alongside continued research into the predictive value of biomarkers and targeted therapies, are recommended to advance understanding of the role of genomic biomarkers. Greater evidence and consensus regarding the clinical and cost-effectiveness of molecular profiling may lead to broader insurance coverage and increased integration into patient care.

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Douglas E. Wood, George A. Eapen, David S. Ettinger, Lifang Hou, David Jackman, Ella Kazerooni, Donald Klippenstein, Rudy P. Lackner, Lorriana Leard, Ann N. C. Leung, Pierre P. Massion, Bryan F. Meyers, Reginald F. Munden, Gregory A. Otterson, Kimberly Peairs, Sudhakar Pipavath, Christie Pratt-Pozo, Chakravarthy Reddy, Mary E. Reid, Arnold J. Rotter, Matthew B. Schabath, Lecia V. Sequist, Betty C. Tong, William D. Travis, Michael Unger and Stephen C. Yang

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David S. Ettinger, Debra K. Armstrong, Sally Barbour, Michael J. Berger, Philip J. Bierman, Bob Bradbury, Georgianna Ellis, Steve Kirkegaard, Dwight D. Kloth, Mark G. Kris, Dean Lim, Laura Boehnke Michaud, Lida Nabati, Kim Noonan, Hope S. Rugo, Darby Siler, Steven M. Sorscher, Sundae Stelts, Lisa Stucky-Marshall, Barbara Todaro and Susan G. Urba

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Douglas E. Wood, Ella A. Kazerooni, Scott L. Baum, George A. Eapen, David S. Ettinger, Lifang Hou, David M. Jackman, Donald Klippenstein, Rohit Kumar, Rudy P. Lackner, Lorriana E. Leard, Inga T. Lennes, Ann N.C. Leung, Samir S. Makani, Pierre P. Massion, Peter Mazzone, Robert E. Merritt, Bryan F. Meyers, David E. Midthun, Sudhakar Pipavath, Christie Pratt, Chakravarthy Reddy, Mary E. Reid, Arnold J. Rotter, Peter B. Sachs, Matthew B. Schabath, Mark L. Schiebler, Betty C. Tong, William D. Travis, Benjamin Wei, Stephen C. Yang, Kristina M. Gregory and Miranda Hughes

Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. Early detection of lung cancer is an important opportunity for decreasing mortality. Data support using low-dose computed tomography (LDCT) of the chest to screen select patients who are at high risk for lung cancer. Lung screening is covered under the Affordable Care Act for individuals with high-risk factors. The Centers for Medicare & Medicaid Services (CMS) covers annual screening LDCT for appropriate Medicare beneficiaries at high risk for lung cancer if they also receive counseling and participate in shared decision-making before screening. The complete version of the NCCN Guidelines for Lung Cancer Screening provides recommendations for initial and subsequent LDCT screening and provides more detail about LDCT screening. This manuscript focuses on identifying patients at high risk for lung cancer who are candidates for LDCT of the chest and on evaluating initial screening findings.