NCCN: Continuing Education
Target Audience: This activity is designed to meet the educational needs of oncologists, nurses, pharmacists, and other healthcare professionals who manage patients with cancer.
Accreditation Statements
In support of improving patient care, National Comprehensive Cancer Network (NCCN) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Medicine (ACCME): NCCN designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Nursing (ANCC): NCCN designates this educational activity for a maximum of 1.0 contact hour.
Pharmacy (ACPE): NCCN designates this knowledge-based continuing education activity for 1.0 contact hour (0.1 CEUs) of continuing education credit. UAN: JA4008196-0000-20-009-H01-P
All clinicians completing this activity will be issued a certificate of participation. To participate in this journal CE activity: (1) review the educational content; (2) take the posttest with a 66% minimum passing score and complete the evaluation at https://education.nccn.org/node/88305; and (3) view/print certificate.
Pharmacists: You must complete the posttest and evaluation within 30 days of the activity. Continuing pharmacy education credit is reported to the CPE Monitor once you have completed the posttest and evaluation and claimed your credits. Before completing these requirements, be sure your NCCN profile has been updated with your NAPB e-profile ID and date of birth. Your credit cannot be reported without this information. If you have any questions, please e-mail education@nccn.org.
Release date: August 10, 2020; Expiration date: August 10, 2021
Learning Objectives:
Upon completion of this activity, participants will be able to:
Integrate into professional practice the updates to the NCCN Guidelines for Survivorship
Describe the rationale behind the decision-making process for developing the NCCN Guidelines for Survivorship
Disclosure of Relevant Financial Relationships
The NCCN staff listed below discloses no relevant financial relationships:
Kerrin M. Rosenthal, MA; Kimberly Callan, MS; Genevieve Emberger Hartzman, MA; Erin Hesler; Kristina M. Gregory, RN, MSN, OCN; Rashmi Kumar, PhD; Karen Kanefield; and Kathy Smith.
Individuals Who Provided Content Development and/or Authorship Assistance:
Crystal S. Denlinger, MD, Panel Chair, has disclosed that she is a scientific advisor for Merck, Exelixis, Bristol-Myers Squibb, and BeiGene; and has received honoraria from Eli Lilly & Co., and Taiho.
Tara Sanft, MD, Panel Vice Chair, has disclosed that she has no relevant financial relationships.
Wendy Demark-Wahnefried, PhD, RD, Panel Member, has disclosed that she has no relevant financial relationships.
Javid J. Moslehi, MD, Panel Member, has disclosed that he is a scientific advisor for Nektar Therapeutics, Novartis Pharmaceuticals Corporation, Bristol-Myers Squibb, Pfizer Inc., and Takeda Pharmaceuticals North America, Inc.
Linda Overholser, MD, MPH, Panel Member, has disclosed that she has equity interest/stock options in Bristol-Myers Squibb Company and royalty income from Springer Publishing.
Nicole R. McMillian, MS, CHES, Guidelines Coordinator, NCCN, has disclosed that she has no relevant financial relationships.
Deborah A. Freedman-Cass, PhD, Manager, Licensed Clinical Content, NCCN, has disclosed that she has no relevant financial relationships.
To view all of the conflicts of interest for the NCCN Guidelines panel, go to NCCN.org/disclosures/guidelinepanellisting.aspx.
This activity is supported by educational grants from AstraZeneca; Celgene Corporation; Coherus BioSciences; Genentech, a member of the Roche Group; and TESARO, a GSK Company. This activity is supported in part by an educational grant from Bayer Healthcare Pharmaceuticals. This activity is supported by an independent medical education grant from Bristol-Myers Squibb. This activity is supported by a medical education grant from Exelixis, Inc. This activity is supported by an independent educational grant from Merck & Co., Inc.
Overview
The number of cancer survivors in the United States increased from approximately 3 million in 1971 to nearly 16.9 million in 2019.1–3 These numbers are predicted to surpass 22 million by 2030.3 This striking increase is generally attributed to increasing cancer incidence rates (mainly resulting from an aging population), earlier detection, and better treatment.
Approximately 64% of survivors were aged ≥65 years in 2019, and an estimated 1 of every 5 persons aged >65 years is a cancer survivor.3 Only 5% are <40 years of age, and survivors of childhood cancer constitute between 0.5% and 3.0% of the survivor population.4,5 The most common cancers in the survivor population are breast, prostate, colon/rectum, and melanoma, together accounting for approximately 58% of survivors.4 Approximately 64% of survivors were diagnosed ≥5 years ago, whereas 15% of survivors were diagnosed ≥20 years ago, and approximately 5% have survived ≥30 years.4
The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Survivorship provide screening, evaluation, and treatment recommendations for consequences of cancer and cancer treatment to aid healthcare professionals who work with survivors of adult-onset cancer. Guidance is also provided to help promote physical activity, a healthful diet and weight management, and proper immunizations in survivors and to facilitate care coordination to ensure that all needs are addressed. The NCCN Survivorship Panel is comprised of a multidisciplinary panel of experts that includes at least one of the following: oncologist, bone marrow transplant clinician, gynecologist, urologist, cardiologist, primary care physician, psychologist, nutrition scientist, nurse, epidemiologist, social worker, and cancer survivor. The panel meets annually to discuss the latest data emerging in the field of survivorship and to decide about requested changes to the guidelines that come from panel members or other health professionals at NCCN Member Institutions (internal requests) or from outside individuals or groups (external requests).
Among the changes the panel made this year were the addition of a new section on cardiovascular disease (CVD) risk assessment and changes to the recommendations related to screening for subsequent primary malignancies. These updates are discussed herein. Other updates can be seen in the complete version of these guidelines, available at NCCN.org.
CVD Risk Assessment
After receiving internal requests from the panel members, the panel decided that it was important to review the data on CVD in cancer survivors and to add recommendations to the guidelines related to CVD risk assessment and risk management in this population.
CVD and cancer are the 2 leading causes of death in the United States, together accounting for approximately 44% of deaths in 2017.6 CVD is also a leading cause of death and the most common cause of noncancer death for survivors of most cancer types.7 In fact, survivors of most cancers have a markedly increased risk of developing CVD compared with noncancer populations.8–10 One reason for this increased CVD risk in cancer survivors is that cytotoxic, hormonal, and targeted systemic cancer therapies (eg, HER2-directed therapy, VEGF signaling pathway inhibitors, cisplatin, anthracyclines with or without taxanes, and androgen deprivation therapy) and radiation therapy are associated with cardiovascular toxicities and can result in diverse cardiovascular issues, including cardiomyopathy, hypertension, hyperlipidemia, cardiac arrhythmia, myocardial infarction, and cerebrovascular accidents.11–17 In addition, shared risk factors for both cancer and CVD likely contribute to the development of CVD and structural heart disease or heart failure in cancer survivors. These risk factors include well-established and well-studied risk factors, such as tobacco use, obesity, and poor health behaviors, as well as recently discovered ones. For example, somatic mutations in blood cells cause clonal hematopoiesis of indeterminate potential (CHIP) and increase the risk of hematologic malignancies, and CHIP is also emerging to be an important causal risk factor for CVD.18 Other well-defined CVD risk factors (eg, hypertension, hyperlipidemia, diabetes) are more common in cancer than noncancer populations.19,20 Most CVDs (eg, atherosclerosis) develop over time as a result of these and other risk factors. Thus, the risk of CVD-related death varies with years from cancer diagnosis, with most survivors being at greatest risk ≥5 years after diagnosis and completion of curative therapy.21
Control of CVD and shared CVD/cancer risk factors can decrease the risk of subsequent cardiovascular events.21,22 Data show that attention to and counseling about CVD/cancer risk factors may improve cancer- and cardiovascular-related outcomes.23 However, data also show that fewer than half of cancer survivors discuss diet, exercise, or smoking or other lifestyle changes with their physician.19,24
The panel discussed the possibility of providing recommendations for CVD risk management in cancer survivors based on a CVD risk group assignment. However, the panel concluded that not enough data are available to define CVD risk groups among cancer survivors. Tools exist to help quantify atherosclerotic CVD risk (eg, ASCVD risk score25), but these tools do not take into account cancer treatment history (eg, anthracycline exposure, tyrosine kinase inhibitor exposure) and thus may not accurately capture true CVD risk in a given survivor.
Therefore, panel consensus was to recommend that physicians provide CVD risk assessment and counseling on CVD risk factor management to all cancer survivors throughout the survivorship continuum. The assessment should include (1) preexisting and emerging CVD, such as coronary artery disease, congestive heart failure, peripheral vascular disease, and arrhythmias including atrial fibrillation; (2) CVD risk factors, including hypertension, dyslipidemia, obesity, and diabetes mellitus; (3) cancer treatment history, such as systemic therapy regimen and radiation field, including cumulative doses received of applicable cardiotoxic therapies; and (4) diet and exercise habits and cigarette/tobacco use (see SCVD-1, page 1019). Counseling should include discussions of any increased risk of CVD the survivor may have based on prior cancer treatment, comorbidity, or CVD risk factors and on the ABCDEs of CVD prevention (see SCVD-2, above). Interventions for modifiable risk factors should be recommended as appropriate. Cooperation and shared care with primary care providers, and with cardiovascular specialists as needed, is key to optimizing cardiac and vascular outcomes in cancer survivors. Referral to cardio-oncology or a cardiology specialist should be considered for cancer survivors deemed to be at high-risk for the development of CVD.
The “ABCDEs to Promote Cardiovascular Wellness in Cancer Survivors” table that the panel added this year was adapted from a paradigm developed to address CVD risk factors in survivors of breast and prostate cancer (see SCVD-2, above).26,27 The table includes items such as aspirin use for secondary prevention (with clinician–survivor discussion required for primary prevention with careful weighing of benefits and risks); blood pressure monitoring/management; cholesterol assessment/management; healthy lifestyle recommendations, including diet/weight management, exercise, and tobacco use; and an echocardiogram and/or electrocardiogram based on individual risk.
Subsequent Primary Malignancies
Subsequent primary cancers are new unrelated cancers in an individual with a history of cancer that are not a recurrence or metastasis of the original primary cancer, with some survivors having more than 2 unrelated primary cancers in their lifetime. The overall incidence of subsequent primary cancers in survivors is higher than the incidence of cancer in the general population because of genetic susceptibilities (eg, hereditary cancer syndromes), shared causative factors (eg, smoking, obesity, environmental exposures, HPV or Epstein-Barr virus infection), and/or the mutagenic effects of cancer treatment.28–38 In fact, subsequent primary cancers accounted for 18% of all cancers diagnosed in the United States between 2009 and 2013.39 These subsequent malignancies are especially well studied in long-term survivors of childhood cancers.40–43 Treatment-related subsequent primary cancers vary with the type and intensity of anticancer treatment and are associated in particular with radiation and specific chemotherapeutic agents.44–50 Studies by individual cancer type show that the incidence of subsequent unrelated cancers ranges from 2% in survivors of malignant lymphoma to 30% in survivors of small cell lung cancer.51 Another study of >2 million cancer survivors in the SEER database identified bladder cancer survivors as having the highest risk for subsequent primary cancers (34% at 20 years).52 Overall, this study found that 8.1% of survivors of cancers diagnosed after age 18 years develop a subsequent malignancy within a mean follow-up of 7.1 years, with 55% of these survivors dying as a result of the subsequent cancer.
With appropriate screening and early detection of subsequent cancers, risk to the cancer survivor can be mitigated. Therefore, the panel has included recommendations for screening for subsequent new primary cancers in survivors in the NCCN Guidelines since 2014.
Role of Genetics
Data suggest that somewhere in the range of 6% to 16% of cancer survivors harbor a germline mutation in a gene associated with oncogenesis,53–56 making genetic predisposition an important driver of subsequent primary cancers. Identification of a germline mutation in a cancer survivor helps establish their risk of developing a subsequent primary malignancy and their need for screening or other risk-reducing measures (eg, surgical, medical). Genetic testing may also have a cascade effect by providing opportunities to identify and reduce risks in relatives of cancer survivors. Several NCCN Guidelines (available at NCCN.org) include management recommendations for patients with known germline mutations linked to an increased risk for cancer.57–59
Based on an external request, the panel reviewed the language in the guidelines regarding hereditary cancer risk assessment and genetic testing in cancer survivors. The panel discussed the fact that not all survivors received a hereditary cancer risk assessment at the time of diagnosis. Furthermore, genetic testing guidelines and knowledge about hereditary cancer risk evolve over time, and new family diagnoses may have occurred since an initial family history evaluation. Therefore, some survivors who previously did not meet criteria for genetic risk assessment may now qualify for genetic testing. Thus, the panel concluded that periodic review of family cancer history in cancer survivors is important to reassess the risk of a hereditary cancer syndrome (see SURV-3, page 1018). The panel consensus was that genetic risk assessment is appropriate for all survivors of breast cancer, epithelial ovarian cancer, high-grade prostate cancer, and pancreatic cancer and for survivors of colorectal or endometrial cancer diagnosed at age ≤50 years. Many other survivors of rare cancers or cancers diagnosed at young ages, those with multiple primary cancers, and those with ≥1 relative with the same or related cancers are also candidates for risk assessment per guidelines from NCCN and other expert groups.57–66 When available, genetic testing is recommended for appropriate survivors based on results of the risk assessment to identify those with an increased risk for subsequent malignancies.
Screening for Subsequent Primary Cancers
Overall, the panel consensus is that screening for subsequent primary cancers should be a shared responsibility between primary and oncology care providers (see NCCN Guidelines for Detection, Prevention, and Risk Reduction, available at NCCN.org). In addition, lifestyle modifications that reduce the risk of subsequent primary cancers (eg, smoking cessation, physical activity, weight loss) should be encouraged.67 As discussed earlier, periodic hereditary cancer assessment, with genetic counseling and testing as appropriate, is also recommended (see SURV-3, page 1018).
Conclusions
Subsequent primary cancers and cardiovascular disease are 2 leading causes of death in cancer survivors. Risk of the former can be mitigated with appropriate cancer screenings and/or cancer risk–reducing measures as informed by treatment exposures and genetic counseling/testing results. Risk of the latter can be reduced by CVD risk assessment and through counseling the survivor on CVD prevention measures, such as lifestyle modification and management of CVD risk factors (eg, blood pressure, cholesterol). The NCCN Survivorship Panel hopes that the guidance added this year will help both oncologic and primary healthcare professionals recognize and optimally manage these risks so that survivors can lead long and rewarding lives.
References
- 1.↑
Bluethmann SM, Mariotto AB, Rowland JH. Anticipating the “silver tsunami”: prevalence trajectories and comorbidity burden among older cancer survivors in the United States. Cancer Epidemiol Biomarkers Prev 2016;25:1029–1036.
- 2.↑
Centers for Disease Control and Prevention (CDC). Cancer survivors—United States, 2007. MMWR Morb Mortal Wkly Rep 2011;60:269–272.
- 3.↑
Miller KD, Nogueira L, Mariotto AB, et al.. Cancer treatment and survivorship statistics, 2019. CA Cancer J Clin 2019;69:363–385.
- 4.↑
DeSantis CE, Lin CC, Mariotto AB, et al.. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin 2014;64:252–271.
- 5.↑
Mariotto AB, Rowland JH, Yabroff KR, et al.. Long-term survivors of childhood cancers in the United States. Cancer Epidemiol Biomarkers Prev 2009;18:1033–1040.
- 7.↑
Zaorsky NG, Churilla TM, Egleston BL, et al.. Causes of death among cancer patients. Ann Oncol 2017;28:400–407.
- 8.↑
Armenian SH, Xu L, Ky B, et al.. Cardiovascular disease among survivors of adult-onset cancer: a community-based retrospective cohort study. J Clin Oncol 2016;34:1122–1130.
- 9.↑
Strongman H, Gadd S, Matthews A, et al.. Medium and long-term risks of specific cardiovascular diseases in survivors of 20 adult cancers: a population-based cohort study using multiple linked UK electronic health records databases. Lancet 2019;394:1041–1054.
- 10.↑
Schoormans D, Vissers PAJ, van Herk-Sukel MPP, et al.. Incidence of cardiovascular disease up to 13 year after cancer diagnosis: a matched cohort study among 32 757 cancer survivors. Cancer Med 2018;7:4952–4963.
- 11.↑
Darby SC, Ewertz M, McGale P, et al.. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med 2013;368:987–998.
- 12.↑
Ky B, Vejpongsa P, Yeh ET, et al.. Emerging paradigms in cardiomyopathies associated with cancer therapies. Circ Res 2013;113:754–764.
- 13.↑
Li W, Croce K, Steensma DP, et al.. Vascular and metabolic implications of novel targeted cancer therapies: focus on kinase inhibitors. J Am Coll Cardiol 2015;66:1160–1178.
- 14.↑
Moslehi JJ. Cardiovascular toxic effects of targeted cancer therapies. N Engl J Med 2016;375:1457–1467.
- 15.↑
O’Farrell S, Garmo H, Holmberg L, et al.. Risk and timing of cardiovascular disease after androgen-deprivation therapy in men with prostate cancer. J Clin Oncol 2015;33:1243–1251.
- 16.↑
Schmid M, Sammon JD, Reznor G, et al.. Dose-dependent effect of androgen deprivation therapy for localized prostate cancer on adverse cardiac events. BJU Int 2016;118:221–229.
- 17.↑
Dess RT, Sun Y, Matuszak MM, et al.. Cardiac events after radiation therapy: combined analysis of prospective multicenter trials for locally advanced non-small-cell lung cancer. J Clin Oncol 2017;35:1395–1402.
- 18.↑
Jaiswal S, Fontanillas P, Flannick J, et al.. Age-related clonal hematopoiesis associated with adverse outcomes. N Engl J Med 2014;371:2488–2498.
- 19.↑
Weaver KE, Foraker RE, Alfano CM, et al.. Cardiovascular risk factors among long-term survivors of breast, prostate, colorectal, and gynecologic cancers: a gap in survivorship care? J Cancer Surviv 2013;7:253–261.
- 20.↑
Meacham LR, Chow EJ, Ness KK, et al.. Cardiovascular risk factors in adult survivors of pediatric cancer--a report from the childhood cancer survivor study. Cancer Epidemiol Biomarkers Prev 2010;19:170–181.
- 22.↑
Gilchrist SC, Barac A, Ades PA, et al.. Cardio-oncology rehabilitation to manage cardiovascular outcomes in cancer patients and survivors: a scientific statement from the American Heart Association. Circulation 2019;139:e997–1012.
- 23.↑
Rasmussen-Torvik LJ, Shay CM, Abramson JG, et al.. Ideal cardiovascular health is inversely associated with incident cancer: the Atherosclerosis Risk In Communities study. Circulation 2013;127:1270–1275.
- 24.↑
Sabatino SA, Coates RJ, Uhler RJ, et al.. Provider counseling about health behaviors among cancer survivors in the United States. J Clin Oncol 2007;25:2100–2106.
- 25.↑
American College of Cardiology. Risk Estimator Plus ASCVD. Accessed March 5, 2020. Available at: http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
- 26.↑
Montazeri K, Unitt C, Foody JM, et al.. ABCDE steps to prevent heart disease in breast cancer survivors. Circulation 2014;130:e157–159.
- 27.↑
Guan J, Khambhati J, Jones LW, et al.. Cardiology patient page. ABCDE steps for heart and vascular wellness following a prostate cancer diagnosis. Circulation 2015;132:e218–220.
- 28.↑
Chen T, Fallah M, Jansen L, et al.. Distribution and risk of the second discordant primary cancers combined after a specific first primary cancer in German and Swedish cancer registries. Cancer Lett 2015;369:152–166.
- 29.↑
Gibson TM, Park Y, Robien K, et al.. Body mass index and risk of second obesity-associated cancers after colorectal cancer: a pooled analysis of prospective cohort studies. J Clin Oncol 2014;32:4004–4011.
- 30.↑
Lam CJ, Curtis RE, Dores GM, et al.. Risk factors for melanoma among survivors of non-Hodgkin lymphoma. J Clin Oncol 2015;33:3096–3104.
- 31.↑
Park SM, Yun YH, Kim YA, et al.. Prediagnosis body mass index and risk of secondary primary cancer in male cancer survivors: a large cohort study. J Clin Oncol 2016;34:4116–4124.
- 32.↑
Ricceri F, Fasanelli F, Giraudo MT, et al.. Risk of second primary malignancies in women with breast cancer: results from the European Prospective Investigation into Cancer and Nutrition (EPIC). Int J Cancer 2015;137:940–948.
- 33.↑
Schaapveld M, Aleman BM, van Eggermond AM, et al.. Second cancer risk up to 40 years after treatment of Hodgkin’s lymphoma. N Engl J Med 2015;373:2499–2511.
- 34.↑
Shiels MS, Gibson T, Sampson J, et al.. Cigarette smoking prior to first cancer and risk of second smoking-associated cancers among survivors of bladder, kidney, head and neck, and stage I lung cancers. J Clin Oncol 2014;32:3989–3995.
- 35.↑
Travis LB, Rabkin CS, Brown LM, et al.. Cancer survivorship—genetic susceptibility and second primary cancers: research strategies and recommendations. J Natl Cancer Inst 2006;98:15–25.
- 36.↑
Wallis CJ, Mahar AL, Choo R, et al.. Second malignancies after radiotherapy for prostate cancer: systematic review and meta-analysis. BMJ 2016;352:i851.
- 37.↑
Wood ME, Vogel V, Ng A, et al.. Second malignant neoplasms: assessment and strategies for risk reduction. J Clin Oncol 2012;30:3734–3745.
- 38.↑
Suk R, Mahale P, Sonawane K, et al.. Trends in risks for second primary cancers associated with index human papillomavirus-associated cancers. JAMA Netw Open 2018;1:e181999.
- 39.↑
Murphy CC, Gerber DE, Pruitt SL. Prevalence of prior cancer among persons newly diagnosed with cancer: an initial report from the Surveillance, Epidemiology, and End Results program. JAMA Oncol 2018;4:832–836.
- 40.↑
Friedman DL, Whitton J, Leisenring W, et al.. Subsequent neoplasms in 5-year survivors of childhood cancer: the Childhood Cancer Survivor Study. J Natl Cancer Inst 2010;102:1083–1095.
- 41.↑
Henderson TO, Oeffinger KC, Whitton J, et al.. Secondary gastrointestinal cancer in childhood cancer survivors: a cohort study. Ann Intern Med 2012;156:757–766, W-260.
- 42.↑
Nottage K, McFarlane J, Krasin MJ, et al.. Secondary colorectal carcinoma after childhood cancer. J Clin Oncol 2012;30:2552–2558.
- 43.↑
Reulen RC, Winter DL, Frobisher C, et al.. Long-term cause-specific mortality among survivors of childhood cancer. JAMA 2010;304:172–179.
- 44.↑
Berrington de Gonzalez A, Curtis RE, Kry SF, et al.. Proportion of second cancers attributable to radiotherapy treatment in adults: a cohort study in the US SEER cancer registries. Lancet Oncol 2011;12:353–360.
- 45.↑
Davis EJ, Beebe-Dimmer JL, Yee CL, et al.. Risk of second primary tumors in men diagnosed with prostate cancer: a population-based cohort study. Cancer 2014;120:2735–2741.
- 46.↑
Dores GM, Curtis RE, van Leeuwen FE, et al.. Pancreatic cancer risk after treatment of Hodgkin lymphoma. Ann Oncol 2014;25:2073–2079.
- 47.↑
Palumbo A, Bringhen S, Kumar SK, et al.. Second primary malignancies with lenalidomide therapy for newly diagnosed myeloma: a meta-analysis of individual patient data. Lancet Oncol 2014;15:333–342.
- 48.↑
Rodriguez AM, Kuo YF, Goodwin JS. Risk of colorectal cancer among long-term cervical cancer survivors. Med Oncol 2014;31:943.
- 49.↑
Wolff AC, Blackford AL, Visvanathan K, et al.. Risk of marrow neoplasms after adjuvant breast cancer therapy: the National Comprehensive Cancer Network experience. J Clin Oncol 2015;33:340–348.
- 50.↑
Wong JR, Morton LM, Tucker MA, et al.. Risk of subsequent malignant neoplasms in long-term hereditary retinoblastoma survivors after chemotherapy and radiotherapy. J Clin Oncol 2014;32:3284–3290.
- 51.↑
Valdivieso M, Kujawa AM, Jones T, et al.. Cancer survivors in the United States: a review of the literature and a call to action. Int J Med Sci 2012;9:163–173.
- 52.↑
Donin N, Filson C, Drakaki A, et al.. Risk of second primary malignancies among cancer survivors in the United States, 1992 through 2008. Cancer 2016;122:3075–3086.
- 53.↑
Wang Z, Wilson CL, Easton J, et al.. Genetic risk for subsequent neoplasms among long-term survivors of childhood cancer. J Clin Oncol 2018;36:2078–2087.
- 54.↑
Wiggins J, McLoughlin A, George A, et al.. Germline BRCA1 and BRCA2 testing for breast cancer survivors [published online September 11, 2019]. J Med Genet, doi: 10.1136/jmedgenet-2019-106420
- 55.↑
Wilson CL, Wang Z, Liu Q, et al.. Estimated number of adult survivors of childhood cancer in United States with cancer-predisposing germline variants. Pediatr Blood Cancer 2020;67:e28047.
- 56.↑
Slavin TP, Sun CL, Chavarri-Guerra Y, et al.. Older breast cancer survivors may harbor hereditary cancer predisposition pathogenic variants and are at risk for clonal hematopoiesis. J Geriatr Oncol 2020;11:316–319.
- 60.↑
Manahan ER, Kuerer HM, Sebastian M, et al.. Consensus guidelines on genetic’ testing for hereditary breast cancer from the American Society of Breast Surgeons. Ann Surg Oncol 2019;26:3025–3031.
- 61.↑
Runowicz CD, Leach CR, Henry NL, et al.. American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline. J Clin Oncol 2016;34:611–635.
- 62.↑
Owens DK, Davidson KW, Krist AH, et al.. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer: US Preventive Services Task Force recommendation statement. JAMA 2019;322:652–665.
- 67.↑
Travis LB, Demark Wahnefried W, Allan JM, et al.. Aetiology, genetics and prevention of secondary neoplasms in adult cancer survivors. Nat Rev Clin Oncol 2013;10:289–301.
NCCN CATEGORIES OF EVIDENCE AND CONSENSUS
Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate.
Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.
All recommendations are category 2A unless otherwise noted.
Clinical trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
PLEASE NOTE
The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. The NCCN Guidelines Insights highlight important changes in the NCCN Guidelines recommendations from previous versions. Colored markings in the algorithm show changes and the discussion aims to further the understanding of these changes by summarizing salient portions of the panel's discussion, including the literature reviewed.
The NCCN Guidelines Insights do not represent the full NCCN Guidelines; further, the National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use, or application of the NCCN Guidelines and NCCN Guidelines Insights and disclaims any responsibility for their application or use in any way.
The complete and most recent version of these guidelines is available free of charge at NCCN.org.
© National Comprehensive Cancer Network, Inc. 2020. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN.
