04/11/2017

NCCN has published updates to the NCCN Guidelines® for Survivorship.

NCCN has published updates to the NCCN Guidelines^® for Survivorship. These NCCN Guidelines are currently available as Version 1.2017. 

• The algorithms were updated for the following sections: General Survivorship Principles, Anthracycline-Induced Cardiac Toxicity, Anxiety/Depression/Distress, Cognitive Function, Fatigue, Menopause-Related Symptoms, Pain, Sexual Function (female and male), Sleep Disorders, and Healthy Lifestyles (Physical Activity, Nutrition and Weight Management, and Supplement Use).
• General Survivorship Principles
  • Standards for Survivorship Care: Bullets describing the components of a survivorship care plan were extensively revised. (SURV-1)
  • Screening for Second Cancers (SURV-3)
    • New bullet added: "Regular updating of family cancer history is recommended to reassess hereditary risk, based on recent family diagnoses and on any new evidence in the field of cancer genetics that expands the basis for assessing inherited risk."
    • Seventh bullet revised: "Referral to genetic risk assessment and/or testing should be considered for appropriate survivors to identify those with a potential increased risk for second malignancies based on genetic profile. Appropriate candidates include survivors with a cancer diagnosis at a young age or with multiple primary cancers.”
  • Minor changes were made to the “Survivorship Baseline Assessment” section. (SURV-A)
• Anthracycline-Induced Cardiac Toxicity (SCARDIO-1)
  • Principles of Anthracycline-Induced Cardiac Toxicity: Third bullet revised, "Survivors may have risk factors that predispose them to heart failure (such survivors are considered to have Stage A heart failure) or may have structural heart disease (such survivors are considered to have Stage B heart failure) even if they have no actual symptoms. A history of anthracycline exposure is a risk factor that (classifies a survivor as having Stage A heart failure) predisposes survivors to cardiac disease."
• Anxiety, Depression, and Distress
  • General Principles: Second bullet revised, "Survivors of cancer treatment are at high elevated risk for mental health issues such as fear of recurrence, distress, anxiety, and depression due to the multiple challenges they face that may persist many years after diagnosis." (SANXDE-1)
  • Screening: Anxiety and Depression
    • Screening questions about symptoms in the past two weeks, revised to include “on more days than not.” (SANXDE-2)
  • Principles of Pharmacologic Interventions (SANXDE-C)
    • Caveats: Fifth bullet revised: "Avoid psychotropics with cytochrome P₄₅₀ interactions in patients taking tamoxifen, or with complicated medical problems or high likelihood for recurrence.
    • Fluvoxamine and Nefazodone were added to the list of psychotropics with cytochrome P450 interactions.
    • New footnote added: "Pure SSRIs, and in particular paroxetine, block conversion of tamoxifen to active metabolites through CYP2D6 and should be used with caution for women on tamoxifen."
• Cognitive Function
  • General Principles (SCF-1)
    • Second bullet revised: "Studies using neurologic Neuropsychological testing and brain imaging provide objective evidence of cognitive dysfunction have demonstrated abnormalities in patients who have had chemotherapy following cancer treatment."
    • New bullet added: "These guidelines address cognitive function of survivors with non-central nervous system (CNS) malignancies who did not have CNS-directed therapies."
• Menopause-related Symptoms
  • Treatment for vasomotor symptoms in females (SMP-4) and males (SMP-5)
    • The following nonpharmacologic treatments were added:
      • Weight loss if overweight or obese 
      • Integrative therapies including cognitive behavioral therapy (CBT), yoga, and hypnosis
    • New footnotes "d" (females) and “i” (males) regarding "Compounds with limited evidence of safety and efficacy" were added.  Previously "Phytoestrogens, botanicals, melatonin, and dietary supplements" were listed under "Nonpharmacologic treatments."
    • Footnote "f" revised: "Recommend avoidance of red wine. Drinking alcohol may cause hot flashes in males/females. Individual responses to alcohol may vary. If alcohol is a trigger, consider limiting intake."
  • Non-hormonal Pharmacologic Treatments and Dosing: The lowest dose possible was specified for all drug classes listed in the table. (SMP-A)
• Pain
  • Skeletal pain (SPAIN-6)
    • General measures for vertebral compression: Recommendation revised, "Bisphosphonates or other antiresorptive medications if appropriate"
    • For avascular necrosis: "Core decompression" was added.
• Sexual Function (Female) (SSF-2)
  • Symptoms of menopause, vaginal dryness...: All treatment options were removed and a link to recommendations in the Menopause-Related Symptoms algorithm was added.
  • Symptoms of pain with sexual activity: Prasterone added as a treatment option.
  • Low or lack of desire, libido, or intimacy: Bupropion and buspirone added as treatment options with corresponding footnote "Bupropion and buspirone may be considered as off-label treatments for hypoactive sexual desire disorder, despite limited safety and efficacy data."
  • Footnote "g" revised: "There is a lack of data showing a benefit of sildenafil in women or of flibanserin and androgens in cancer survivors. In addition there is a lack of safety data for the use of androgen-based therapy in survivors of hormonally mediated cancers."
• Sleep Disorders
  • Screening (SSD-1)
    • Screening question changed “Are you having problems falling asleep, staying asleep, or waking up too early?” 
    • Under “Assessment of treatable or modifiable contributing factors,” Comorbidities revised: "Neurologic disorders including chemotherapy-induced peripheral neuropathy"
    • Revised: "Insomnia symptoms (difficulty falling asleep and/or maintaining sleep, staying asleep, or waking up too early)"
  • General Sleep Hygiene Measures (SSD-A)
    • Fifth bullet revised: "Avoid alcohol, caffeine, and nicotine too close to bedtime."
    • New bullet added: "Limit caffeine consumption and avoid caffeine consumption at least 4 hours before bedtime."
    • Eleventh bullet revised: "If necessary, limit to 1 short nap per day in the afternoon (no longer than 30 min).
  • Cognitive Behavioral Treatments (SSD-B)
    • Sleep restriction revisions
      • "Maintaining a regular sleep schedule by keeping a standard bedtime and wake time every day."
      • New footnote regarding limiting time in bed added: "Match total amount of time spent in bed to the actual amount of time spent sleeping (no less than 5 hours)."
    • Relaxation training: "Techniques include progressive muscular relaxation, deep breathing, transcendental meditation, yoga, and biofeedback."
• Healthy Lifestyles (including Physical Activity, Nutrition and Weight Management, and Supplement Use) (HL-1)
  • This section was extensively revised.

For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Drugs & Biologics Compendium (NCCN Compendium^®), the NCCN Biomarkers Compendium^®, the NCCN Chemotherapy Order Templates (NCCN Templates^®), and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), please visit NCCN.org.