An Interdisciplinary Care Approach for Integration of Palliative Care in Lung Cancer

PurposeQuality of Life (QOL) and symptom concerns are common in lung cancer. This article presents findings from 2 separate pilot studies that utilize an educational model to reduce barriers to pain and fatigue management (“barriers study”) and an interdisciplinary palliative care approach to manage QOL concerns for patients with lung cancer (“QOL pilot”).Patients and MethodsIn the barriers study, a total of 46 patients with lung cancer with a self-reported pain and/or fatigue rating of ≥ 4 were accrued, with 18 patients in the usual care group and 28 in the experimental group, using a quasi-experimental design. This study involved a 4-part educational intervention delivered by a nurse to address pain and fatigue. In the QOL study, the pilot intervention included 10 patients with lung cancer. This pilot included use of QOL assessment completed by a nurse followed by an interdisciplinary case conference intended to initiate supportive care to address QOL and symptom concerns. Patient-reported outcomes such as barriers to pain and fatigue management, fatigue intensity, other symptoms, and overall QOL were analyzed through tabulation of standard summary statistics and multivariate analysis methods. All eligible patients were recruited from the ambulatory clinic of one National Cancer Institute–designated Comprehensive Cancer Center.ResultsFor the barriers study, patients with lung cancer in the experimental group had a statistically significant decrease in patient-related barriers for both pain and fatigue. Findings from the QOL pilot revealed that patients with lung cancer have multiple QOL concerns and that an interdisciplinary palliative care approach was feasible to address these complex, multidimensional patient needs.ConclusionAttention to barriers of symptom management, early referral to supportive care services, and coordination of interdisciplinary care are essential to supporting the QOL of patients with lung cancer. The next phase of this research will test QOL/symptom interventions for patients with lung cancer.     

Recommendations for Palliative and Hospice Care in NCCN Guidelines for Treatment of Cancer

BackgroundIntegration of specialist palliative care into routine oncologic care improves patients’ quality of life and survival. National Comprehensive Cancer Network (NCCN) cancer treatment guidelines are instrumental in standardizing cancer care, yet it is unclear how palliative and hospice care are integrated in these guidelines. In this study, we examined the frequency of occurrence of “palliative care” and “hospice care” in NCCN guidelines and compared between solid tumor and hematologic malignancy guidelines.Materials and MethodsWe reviewed all 53 updated NCCN Guidelines for Treatment of Cancer. We documented the frequency of occurrence of “palliative care” and “hospice care,” the definitions for these terms if available, and the recommended timing for these services.ResultsWe identified a total of 37 solid tumor and 16 hematologic malignancy guidelines. Palliative care was mentioned in 30 (57%) guidelines (24 solid tumor, 6 hematologic). Palliative care was mentioned more frequently in solid tumor than hematologic guidelines (median, 2 vs. 0; p = .04). Among the guidelines that included palliative care in the treatment recommendation, 25 (83%) only referred to NCCN palliative care guideline. Specialist palliative care referral was specifically mentioned in 5 of 30 (17%) guidelines. Only 14 of 24 (58%) solid tumor guidelines and 2 of 6 (33%) hematologic guidelines recommended palliative care in the front line setting for advanced malignancy. Few guidelines (n = 3/53, 6%) mentioned hospice care.Conclusion“Palliative care” was absent in almost half of NCCN cancer treatment guidelines and was rarely discussed in guidelines for hematologic malignancies. Our findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.Implications for PracticeIntegration of specialist palliative care into routine oncologic care is associated with improved patient outcomes. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology have an important role to standardize palliative care involvement for cancer patients. It is unclear how often palliative care referral is recommended in these guidelines. In this study involving 53 NCCN Guidelines for Treatment of Cancer, the researchers found that palliative care was not mentioned in over 40% of NCCN guidelines and was rarely discussed in guidelines for hematologic malignancies. These findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.     

Breast cancer treatment in clinical practice compared to best evidence and practice guidelines

There is sparse evidence on community practice patterns in treating women with breast cancer. This study compared care of women with breast cancer with evidence from meta-analyses and US National Comprehensive Cancer Network (NCCN) clinical guidelines. Records of 4395 women with breast cancer were abstracted from practices of 19 surgeon oncologists in six specialty practices in the Philadelphia region during 1995-1999. Patients were followed through December 2001. Low-frequency data were obtained on all patients. All other data were from a random sample of 464 women, minimum of 50 patients per practice. Actual care provided was compared to NCCN guidelines and results of meta-analyses. Fewer than half the women received treatments reflecting meta-analysis results or NCCN guidelines, by disease stage/TNM status. Adherence to either standard varied from 0% for LCIS to 87% for stages IIA or IIB node positive. There are multiple interactive reasons for low adherence to guidelines or meta-analyses results, including insufficient health system supports to clinicians, inadequate organisation and delivery systems and ineffective continuing medical education. The paucity of written information from patient records on physician/patient interactions limits the understanding of treatment decisions.     

Health Care Disparities and Demand for Expanding Hereditary Breast Cancer Screening Guidelines in African Americans

BackgroundGenomic medicine has led to significant advancements in the prevention and treatment of cancer. The National Comprehensive Cancer Network (NCCN) guidelines recommend BRCA1/2 screening in high-risk individuals; however, the guidelines have not incorporated differences within ethnic cohorts beyond Ashkenazi Jewish ethnicity. We analyzed the prevalence of BRCA1/2 mutations in various ethnicities and identified high-risk personal characteristics and family history incorporating differences within ethnic cohorts beyond Ashkenazi Jewish ethnicity.Patients and MethodsWe reviewed data collected by a Michigan medical genetic clinic in a community-based hospital from 2008 to 2018. A retrospective chart analysis was conducted of 1090 patients who received genetic counseling regarding hereditary cancer syndromes.ResultsWe found a statistically significant higher rate of pathogenic BRCA1/2 mutation prevalence in African American patients, at 8.1%, compared to non-Ashkenazi Jewish white patients, at 3.6% (P = .02). African Americans have a mutational prevalence nearing that of the Ashkenazi Jewish population.ConclusionRevision of the NCCN guidelines regarding hereditary cancer syndrome testing in various ethnic groups is imperative and overdue. Future studies are needed to identify health care disparities in and socioeconomic barriers to genetic testing.     

Association between adherence to National Comprehensive Cancer Network treatment guidelines and improved survival in patients with colon cancer

BACKGROUND:

The objective of the current study was to examine the impact of adherence to guidelines on stage‐specific survival outcomes in patients with stage III and high‐risk stage II colon cancer. The National Comprehensive Cancer Network (NCCN) has established working, expert consensus, and evidence‐based guidelines for organ‐specific cancer care, including care of patients with colon cancer.

METHODS:

Patients who were diagnosed with colon adenocarcinoma between 1998 and 2002 were selected from within the National Cancer Data Base. The cohort was limited to patients who received their first course of treatment at the reporting facility. Pathologic variables, including tumor depth, lymph node status, and evidence of metastatic disease, were used to restage patients, and the patients were divided into low‐risk and high‐risk categories on the basis of criteria defined by the NCCN. Relative survival rates were calculated for the entire cohort, stratified according to adherence versus nonadherence to NCCN treatment guidelines.

RESULTS:

In univariate analysis of treatment adherence patterns for both patient subgroups (high‐risk stage II and stage III), several factors were associated with a higher rate of nonadherence in both groups, including older age (P < .001); Medicaid, Medicare, or uninsured status versus private insurance (P < .001); and subsequent treatment at a facility other than the facility at which the cancer was first diagnosed (P < .001). In multivariate analysis, multiple factors were associated with differences in relative survival, although analyses that included the year of diagnosis did not demonstrate significant differences over time.

CONCLUSIONS:

The current study documented practice patterns in a heterogeneous population of patients with colon cancer and demonstrated a survival benefit for patients with stage III and high‐risk stage II colon cancer who received treatment that adhered to NCCN guidelines. These data validate the current NCCN practice guidelines for colon cancer and support the concept of guideline‐based metrics that can be compared across institutions to assess the quality of cancer care and to compare the quality of cancer care among institutions. Cancer 2013. © 2012 American Cancer Society.     

Screening for psychosocial distress: a national survey of oncologists

Little is known about the dissemination and uptake of National Comprehensive Cancer Network (NCCN) guidelines for psychosocial distress in oncology practice. This study surveyed oncologists about their awareness of NCCN guidelines on psychosocial distress and their methods of screening patients for distress. In all, 1,000 oncologists practicing in the United States who were members of the American Society of Clinical Oncology were asked to complete an anonymous questionnaire. Predictors of routine screening for distress were identified using logistic regression. Overall, 46% (448/965) of the oncologists responded. Almost two thirds (63.4%) practiced in the community, 27.2% practiced in cancer centers, and 6.9% practiced in hospitals. Less than one-third (32.3%) reported being at least somewhat familiar with NCCN guidelines. Two-thirds (65.0%; 95% confidence interval, 60.6-69.4) reported screening patients for distress routinely, but only 14.3% used a screening instrument. Independent predictors for screening patients for distress included availability of mental health services, knowledge of NCCN guidelines, experience, lack of time, uncertainty about identifying distress, and female gender of the practitioner. NCCN guidelines for psychosocial distress do not appear to be widely disseminated. Whereas the majority of oncologists reported routinely screening patients for distress, only a small percentage followed the guidelines by using a screening instrument. Future efforts should focus on the dissemination and validation of the NCCN guidelines.     

Radiotherapy Utilization for Patients Over Age 60 With Early Stage Breast Cancer

IntroductionRecent studies have questioned the relative benefit of radiotherapy (RT) for older patients with favorable breast cancer given the lack of survival benefit and marginal local control benefit. Despite the 2004 National Comprehensive Cancer Network (NCCN) guidelines advocating for the option of hormonal therapy alone, trends in utilization rates of RT in this group are not well-documented. We analyzed our institutional experience with implementation of the guidelines over time.Material and MethodsWe identified 564 patients aged ≥ 60 years with favorable breast cancer treated with breast conserving surgery from 2000 to 2017. Patients met criteria for Cancer and Leukemia Group B (CALGB) 9343, Postoperative Radiotherapy in Minimum Risk Elderly (PRIME II), or the very-low risk cohort identified in the Toronto-British Columbia study. Multivariable logistic regression analysis was performed to assess the magnitude of association between omission status, grade, and tumor size while controlling for age and year of diagnosis.ResultsOverall RT omission rates were 17.6% prior to the 2004 NCCN update and 45% after the publication of the 10-year CALGB data in 2013. The overall RT omission rate was 29%. Patients with grade 1 to 2 histology (odds ratio, 3.2; 95% confidence interval, 1.3-7.7; P = .01) and tumors < 1 cm (odds ratio, 1.60; 95% confidence interval, 0.4-0.9; P = .007) were more likely to omit RT than those with higher grade or larger tumors.ConclusionsWe observed a slight decrease in the use of RT over time, suggesting a move towards adoption of the NCCN guidelines. There remains a fundamental need to continue to individualize breast cancer care based on risk stratification and make evidenced-based treatment recommendations with equitable use of health care resources.     

厄洛替尼治疗对晚期非小细胞肺癌患者生活质量的影响

目的 探讨厄洛替尼单药二线或三线治疗对晚期非小细胞肺癌(NSCLC)患者生活质量的影响.方法 经化疗失败的Ⅲb期和Ⅳ期NSCLC患者50例,口服厄洛替尼150 mg/d,直至疾病进展.采用欧洲癌症研究和治疗组织(EORTC)的生活质量调查核心问卷QLQ-C30和肺癌专用问卷QLQ-LC13,对治疗前后患者的生活质量和症状评价.结果 47例患者可以评价疗效,其中部分缓解18例,稳定(SD)21例,进展(PD)8例.厄洛替尼治疗2个周期后,48例患者完成了问卷.与治疗前比较,除认知功能外,体格、角色、情感、社会4种功能状态和整体生活质量评分均显著提高(均P<0.05);乏力和食欲不振两个全身症状以及除咯血外的疾病相关症状评分显著降低(P<0.05).5种功能状态和整体生活质量的有效率均≥44%,乏力和食欲不振两个全身症状以及除咯血外的疾病相关症状有效率均≥46%.生活质量和症状与临床疗效有关(P<0.05),不同临床疗效患者间的主要症状恶化时间差异有统计学意义(P<0.001).结论 厄洛替尼用于二、三线治疗,不仅能够延长晚期NSCLC患者的生存时间,还能够显著改善肺癌相关症状,提高患者的生活质量.生活质量和症状的改善与临床疗效相关.     

2022年第3版《NCCN非小细胞肺癌临床实践指南》更新解读

美国国家综合癌症网络(National Comprehensive Cancer Network,NCCN)是由32家世界知名癌症中心组成的非营利性联盟组织,旨于提供更优质、高效和合理的癌症患者管理模式。NCCN每年持续更新临床实践指南,指南以临床研究数据为依据,确保肿瘤领域专家和患者均能获取最新的癌症预防、筛选和治疗方法,从而达到最佳疗效。NCCN指南不仅是美国肿瘤领域临床决策的标准,而且是全球肿瘤临床实践最广泛的指南。2022年《NCCN非小细胞肺癌临床实践指南》目前更新至第3版,较2021年第7版指南主要在临床评估、分子标志物检测、围手术期治疗、放疗、晚期非小细胞肺癌靶向治疗和免疫治疗等方面进行更新。本文就新版指南更新内容进行逐一解读。     

解读美国国家综合癌症网络食管癌临床诊疗指南

 美国国家综合癌症网络（National Comprehensive Cancer Network，NCCN）是由美国21个国际顶尖水平的癌症中心组成的协作组织，其主要任务是制定各类肿瘤的临床诊疗指南，目的是改善肿瘤治疗的质量、有效性和效率，以使患者更好地生存。目前，NCCN的肿瘤临床诊疗指南已经广泛应用于临床，并且根据最新的临床研究结果每年更新。关于NCCN食管癌临床诊疗指南目前国内还没有正式版本，也没有在临床推广执行。现对2007年NCCN食管癌临床诊疗指南进行解读，并与中国目前临床实践进行对照。     

A brief symptom index for advanced lung cancer

BackgroundAdvanced lung cancer is often symptomatic; thus the goals of treatment include maintenance of function and palliation of symptoms. Symptom management requires accurate systematic symptom assessment. This study, which focused on lung cancer, is part of a larger study to obtain patient input that, in combination with previously obtained physician and nurse input, was used to develop symptom indexes for 11 advanced cancers.Participants and MethodsFifty patients with advanced lung cancer were recruited from National Comprehensive Cancer Network (NCCN) member institutions and community support agencies; 10 physician experts were recruited from NCCN institutions. Patients reported symptoms associated with their disease in open-ended format and then completed a checklist of symptoms, rating their 5 most important symptoms. Patient and provider ratings of symptom importance were tabulated to construct the NCCN-Functional Assessment of Cancer Therapy (FACT) Lung Symptom Index-17 (NFLSI-17). Patients also completed the Functional Assessment of Cancer Therapy-Lung (FACT-L), which was used to preliminarily validate the NFLSI-17.ResultsBased on combined patient, physician, and nurse input, the NFLSI-17 is composed of 17 priority symptoms, 11 that are disease related, 3 that are treatment related, and 3 that are related to general functional well-being (FWB). Data on 15 of 17 NFLSI-17 symptoms showed good internal consistency (alpha = 0.74) and strong association with the FACT-L total and most subscale scores (r = 0.42-0.92). Both the NFLSI-15 (F(2,47) = 4.46; P = .017) and the NFLSI-disease related subscale (DRS) (F(2,47) = 5.56; P = .007) significantly discriminated patients among performance status groups.ConclusionThe NFLSI-17 reflects the most important patient- and clinician-rated targets of chemotherapy for advanced lung cancer; further validation will follow.     

Everolimus vs. Temsirolimus for Advanced Renal Cell Carcinoma: Use and Use of Resources in the US Oncology Network

BackgroundThe National Comprehensive Cancer Network (NCCN) guidelines suggest the use of inhibitors of mammalian target of rapamycin (mTOR), such as temsirolimus and everolimus, as first- and second-line therapy, respectively, for advanced or metastatic renal cell carcinoma (mRCC). However, adherence to this recommendation in clinical practice and the use of these 2 agents in mRCC is unknown.Patients and MethodsWe determined the prescribing patterns of temsirolimus and everolimus in a retrospective longitudinal cohort study of patients with mRCC receiving clinical care within The US Oncology Network. Outpatient health care use in patients with mRCC was derived for the categories of laboratory visits, acute care visits, minor procedures, radiation therapy, drug/medication use, and other services.ResultsAmong 462 patients with mRCC, 144 (31%) were treated with everolimus and 318 (69%) were treated with temsirolimus. The use of temsirolimus vs. everolimus as first-, second-, and third-line therapy was 50.7% vs. 16.7%, 30.1% vs. 42.1%, and 19.3% vs. 83.2%, respectively. Despite similarities in disease stage and demographic features, compared with temsirolimus, everolimus use was independently associated with lower use of outpatient health care resources, regardless of the line of therapy.ConclusionNotwithstanding the potential limitation that this was an observational retrospective study, our results indicate that everolimus results in substantial savings in the use of resources relative to temsirolimus. In a large geographically dispersed network of community-based oncology practices, both of these agents are used frequently outside of NCCN guidelines. A direct comparison of the efficacy and costs of everolimus vs. temsirolimus for mRCC is warranted.     

Psychosocial Factors in Lung Cancer

Abstract

Lung cancer is the leading cause of cancer mortality in men and women. Lung cancer accounts for approximately 30% of all cancer deaths in the United States. In addition, it is the most often diagnosed cancer in men, and the second most often diagnosed cancer in women. Five-year survival rates in lung cancer remain very low, around 15%. Approximately 45% of patients present with stage III disease. The majority of these patients are considered non-resectable, leading to the poor survival statistics seen in this disease. Unfortunately, survival rates have not improved in the past 30 years despite much research in diagnostics and therapeutics. Patients with advanced disease often experience multiple symptoms, including fatigue, pain, dyspnea, cough, hemoptysis, and anorexia. This paper will review the enormous toll that lung cancer takes on society, as well as individuals and families affected. In addition, we will examine psychosocial factors pertinent to lung cancer. Specifically, the article briefly discusses treatment approaches to lung cancer, as they relate to quality of life (QOL). QOL as a construct within lung cancer is then reviewed. Comment is made on the evaluation and prognostic importance of QOL. Next, economic and survivorship aspects of lung cancer are discussed. Finally, a summary of relevant psychosocial interventions for patients diagnosed with lung cancer is given.     

Treatment heterogeneity and overall survival in patients with advanced/metastatic gastric or gastroesophageal junction adenocarcinoma in the United States

BackgroundGastric or gastroesophageal junction (GEJ) adenocarcinoma is the most common form of gastric cancer diagnosed in the United States (US) each year. Diagnosis typically is in later stages of disease when it has advanced. Patients have been treated with a variety of regimens.MethodsThe goal of this retrospective study was to understand if treatment patterns were becoming more homogeneous or remaining heterogeneous using the Herfindahl-Hirschman index (HHI) and if treatments were becoming more concordant to treatment guidelines published by the National Comprehensive Cancer Network (NCCN). HHI scores were calculated for each site by 2-year increments. Trend analyses were conducted for HHI scores over time using a linear regression model. Concordance to Category 1 and any category NCCN guidelines was determined based on the date treatment was initiated with the version of the NCCN guidelines at that time. Time trend analyses were conducted using linear regression models. This study utilized data from the Flatiron Advanced Gastric/Esophageal cohort. This study also examined overall survival (OS) rates estimated by the Kaplan-Meier method by line of therapy.ResultsThere were no statistically significant differences in HHI scores in the first-line setting over time, suggesting heterogeneity has not improved. Concordance to NCCN treatment guidelines for any category significantly increased over time, however Category 1 regimen concordance remained low in the first-line setting. Concordance over time improved in second-line treatment. Median OS from the start of first-line therapy was 13.57 months. There was no relationship between OS time from initiation of first-line therapy and HHI score, concordance with NCCN guidelines, or concordance with NCCN Category 1 guidelines in the first-line setting.ConclusionsTreatment heterogeneity persists in gastric cancer care, though there is a significant association between heterogeneity and concordance with both Category 1 and any category in the NCCN treatment guidelines, and that concordance has increased over time.     

Aromatase Inhibitor Symptom Management Practices: A Retrospective Study

PurposeAromatase inhibitor (AI)-associated symptoms contribute to early therapy discontinuation. Although guidelines exist for management of these symptoms, little is known about the degree to which physicians address symptoms and adhere to the guidelines for treatment.Patients and MethodsIn this retrospective chart review, women with hormone receptor–positive breast cancer who were prescribed an AI between October 15, 2012, and September 14, 2017, were randomly selected from the institution’s cancer registry. Patient medical records were reviewed to identify the prevalence of symptom documentation and management. Documented symptoms were categorized into musculoskeletal, vasomotor, and urogenital. Symptom treatment guidelines were compiled from the National Comprehensive Cancer Network (NCCN) and the American Cancer Society/American Society of Clinical Oncology (ACS/ASCO). Treatments were categorized as either meeting or not meeting the guidelines. Among patients with symptoms recorded, chi-square tests and time-to-event models were used to examine factors associated with treatment and factors associated with guideline-based treatment.ResultsAmong 179 women prescribed an AI, 82% had at least one symptom and 46% had multiple symptoms. Of the 147 women with any documented symptom, 97 (66%) received some form of symptom-palliating treatment. Seventy-seven patients (52%) received guideline-based treatments or guideline-based treatments in combination with non–guideline-based treatments. There were no differences in receipt of treatment overall (ie, guideline based or non–guideline based) for either vasomotor or musculoskeletal symptoms by age, race, or stage.ConclusionAlthough 82% of patients had symptoms documented in their medical records, just over half of those patients received guideline-based treatment.     

Calibrated Regression Models Based on the Risk of Clinical Nodal Metastasis Should be Used as Decision Aids for Prostate Cancer Staging to Reduce Unnecessary Imaging

IntroductionRadionuclide imaging will change the role of computed tomography and magnetic resonance imaging (CT/MRI) for prostate cancer (CaP) staging. Current guidelines recommend abdominopelvic imaging for new cases of CaP categorized as unfavorable intermediate risk (UIR) or higher. We assessed the performance characteristics of CT/MRI based on the National Comprehensive Cancer Network (NCCN) guidelines and developed a model that predicts cN1 disease using conventional imaging.Patients and MethodsWe selected patients in the National Cancer Database diagnosed with CaP from 2010 to 2016 with available age, prostate specific antigen, clinical locoregional staging, biopsy Gleason grading, and core information. Multivariate logistic regression (MLR) was used on a undersampled training dataset using cN1 as the outcome. Performance characteristics were compared to those of the three most recent versions of the NCCN guidelines.ResultsA total of 443,640 men were included, and 2.5% had cN1 disease. Using CT/MRI only, the current NCCN guidelines have a sensitivity of 99%, and the number needed to image (NNI) is 24. At the same sensitivity, the cN1 risk was 1.6% using the MLR. The NNI for UIR alone is 341. Using the MLR model and a threshold of 10%, the PPV is 10.3% and 64% of CTs/MRIs could be saved at a cost of missing 6% of cN1 patients (or 0.15% of all patients).ConclusionThe NCCN guidelines are sensitive for detecting cN1 with CT/MRI, however, the number needed to image is 24. Obtaining CT/MRI for nodal staging when patients have a cN1 risk of 10% would reduce total imaging while still remaining sensitive. As novel PET tracers becomes increasingly used for initial CaP staging, well calibrated prediction models trained on the outcome of interest should be developed as decision aids for obtaining imaging.     

What are the most important symptom targets when treating advanced cancer? A survey of providers in the National Comprehensive Cancer Network (NCCN)

We derived a set of brief, clinically relevant symptom indices for assessing symptomatic response to chemotherapy for advanced bladder, brain, breast, colorectal, head and neck, hepatobiliary/pancreas, lung, ovarian, and prostate cancers. Questions were extracted from a multidimensional cancer quality of life (QOL) measurement system, the Functional Assessment of Cancer Therapy (FACT). Surveys of disease-related symptoms were presented to expert physicians and nurses at 17 National Comprehensive Cancer Network (NCCN) member institutions. In a two-step procedure, each expert narrowed the list to no more than five of the very most important to attend to when assessing the value of drug treatment for advanced disease. Symptoms endorsed at a frequency greater than chance probability were retained for the nine symptom indices. The resulting NCCN/FACT symptom indices are comprised of 6-15 items, depending on disease. Fatigue, pain, nausea, weight loss, worry about worsening condition, and contentment with current QOL were consistently selected by experts as priority symptoms across tumor sites. These nine tumor-specific symptom indices indicate the most important clinician-rated targets of chemotherapy for many advanced cancers. These results await validation in patient populations and examination of the extent to which changes in symptomatology translate into meaningful improvement to the patient.     

Assessment of the External Validity of the National Comprehensive Cancer Network and European Society for Medical Oncology Guidelines for Non–Small-Cell Lung Cancer in a Population of Patients Aged 80 Years and Older

Non–small-cell lung cancer (NSCLC) is a disease of the elderly, who are under-represented in clinical trials. This challenges the external validity of the evidence base for its management and of current guidelines, that we evaluated in a population of older patients. We retrieved randomized clinical trials (RCTs) supporting the guidelines and identified 18 relevant topics. We matched a cohort of NSCLC patients aged older than 80 years from the Moffitt Cancer Center database with the studies' eligibility criteria to check their qualification for at least 2 studies. Eligibility > 60% was rated full validity, 30% to 60% partial validity, and < 30% limited validity. We obtained data from 760 elderly patients in stage-adjusted groups and collected 244 RCTs from the National Comprehensive Cancer Network (NCCN) and 148 from the European Society for Medical Oncology (ESMO) guidelines. External validity was deemed insufficient for neoadjuvant chemotherapy in stage III disease (27.37% and 25.26% of patients eligible for NCCN and ESMO guidelines, respectively) and use of bevacizumab (13.86% and 16.27% of patients eligible). For ESMO guidelines, it was inadequate regarding double-agent chemotherapy (25.90% of patients eligible), its duration (24.10%) and therapy for Eastern Cooperative Oncology Group performance status 2 patients (17.74%). For NCCN guidelines external validity was lacking for neoadjuvant chemoradiotherapy in stage IIIA disease (25.86% of patients eligible). Our analysis highlighted the effect of RCT eligibility criteria on guidelines' external validity in elderly patients. Eligibility criteria should be carefully considered in trial design and more studies that do not exclude elderly patients should be included in guidelines.     

The NCCN Clinical Practice Guidelines on Venous Thromboembolic Disease: strategies for improving VTE prophylaxis in hospitalized cancer patients

The risk for venous thromboembolism (VTE) is high in hospitalized cancer patients, and is associated with an elevated risk for recurrent thrombosis, bleeding complications, and use of health care resources. Thromboembolism is the second leading cause of death in hospitalized cancer patients. Thromboprophylaxis with unfractionated heparin or low-molecular-weight heparins has been clinically proven to reduce the risk for VTE and improve outcomes. However, VTE prophylaxis continues to be underprescribed in cancer patients. Recognizing the clinical burden of VTE in cancer patients, the National Comprehensive Cancer Network (NCCN) recently released guidelines for VTE prevention and management. These NCCN guidelines recommend evidence-based prophylactic anticoagulant therapy for all patients admitted to hospital with a diagnosis of cancer who do not have contraindications to anticoagulant use. However, there continue to be barriers to the implementation of clinical practice guidelines and appropriate use of VTE prophylaxis. Multifaceted active educational and electronic interventions are necessary to raise awareness and reduce the burden of cancer-associated thrombosis and its attendant consequences.