Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is characterized by the accumulation of abnormal lymphocytes in the blood, bone marrow, and lymphoid tissues, leading to a weakened immune system and an increased risk of infections for patients. The NCCN Guidelines for CLL/SLL underscore the need for a comprehensive evaluation of multiple factors to determine the most appropriate treatment approach for each patient. For frontline therapy, the selection process should consider the patient’s IGHV status, del(17p)/TP53 mutation status, age, and comorbidities. In choosing subsequent therapy, prior therapy, comorbidities, and resistance mutations should be considered. With no clear evidence of a functional cure, it is important to enroll patients in clinical trials when available.
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Presented by: Deborah M. Stephens
Presented by: Mazyar Shadman and Deborah M. Stephens
In the era of newer, highly effective targeted therapies for chronic lymphocytic leukemia (CLL), experts debated whether there is still a role for chemoimmunotherapy in the first-line setting for the treatment of this disease. In general, targeted therapies are preferred as first-line treatment for all patients, with the exception of low-risk patients [younger, fit patients with mutated IGHV who are candidates for fludarabine/cyclophosphamide/rituximab (FCR)]. About 37% of low-risk patients experience long-term durable remissions and remain stable after treatment with FCR for many years. Advantages of FCR over small molecule inhibitors include cost, fixed duration treatment, and long-term survival benefit. Disadvantages are an etimated 5% risk of developing myelodysplastic syndrome or acute myeloid leukemia. Advantages of small molecule inhibitors are improvements in progression-free and overall survival and quality of life when compared with chemoimmunotherapy. Disadvantages of small molecule inhibitors are high cost and the need for continuous treatment. However, studies are underway to develop fixed duration regimens with combinations of small molecule inhibitors that aim to deepen remissions.
Margaret Kelsey Baron, Ania Shestakova, Tony D Pomicter, Justin Williams, Srinivas K Tantravahi, Ami B Patel, and Deborah M Stephens
Dorothy Romanus, Martin R. Weiser, John M. Skibber, Anna Ter Veer, Joyce C. Niland, John L. Wilson, Ashwani Rajput, Yu-Ning Wong, Al B. Benson III, Stephen Shibata, and Deborah Schrag
Background
The National Comprehensive Cancer Network (NCCN) Outcomes Database was created to assess concordance to evidence- and consensus-based guidelines and to measure adherence to quality measures on an ongoing basis. The Colorectal Cancer Database began in 2005 as a collaboration among 8 NCCN centers.
Methods
Newly diagnosed colon and rectal cancer patients presenting to 1 of 8 NCCN centers between September 1, 2005, and May 21, 2008, were eligible for analysis of concordance with NCCN treatment guidelines for colorectal cancer and with a set of quality metrics jointly developed by ASCO and NCCN in 2007. Adherence rates were determined for each metric. Center-specific rates were benchmarked against mean concordance rates for all participating centers.
Results
A total of 3443 patients were evaluable. Mean concordance rates with NCCN colorectal cancer guidelines and ASCO/NCCN quality measures were generally high (≥ 90%). However, relatively low mean concordance rates were noted for adjuvant chemotherapy treatment recommendations within 9 months of diagnosis of stage II to III rectal cancer (81%), and neoadjuvant chemoradiation in clinical T4 rectal primaries (83%). These low rates of concordance seemed to be consistent across centers.
Conclusions
Adherence to guidelines and quality measures is generally high at institutions participating in the NCCN colorectal cancer database. Lack of documentation, patient refusal, delayed treatment initiation, and lack of consensus about whether treatment was essential were the primary reasons for nonconcordance. Measurement of concordance and the reasons for nonconcordance enable participating centers to understand and improve their care delivery systems.
