NCCN Updates Colorectal and Breast Cancer Guidelines

The National Comprehensive Cancer Network (NCCN) has announced the addition of a survivorship section to the NCCN Clinical Practice Guidelines in Oncology for colon and rectal cancers, as well as other key updates in colorectal cancer. The NCCN also recently updated its guidelines for breast cancer and breast cancer risk reduction. These changes reflect leading developments in the treatment of cancer patients and represent the standard of clinical policy in oncology in both community and academic settings.

Colorectal Cancer Survivorship
The new section dedicated to survivorship provides recommendations for long-term follow-up care of patients treated for colorectal cancer. Specific information is provided about managing possible long-term side effects of treatment, routine screening and monitoring, healthy lifestyle and wellness counseling, and making the transition back into the care of a primary care physician. This section was added to help oncologists support their patients with the complex issues they face after treatment.

The NCCN guidelines continue to incorporate new research about the widely publicized KRAS gene test. In November 2008, NCCN announced modifications to the Guidelines for colon and rectal cancers that included the recommendation for KRAS testing for all patients with a diagnosis of metastatic colorectal cancer based on a number of studies demonstrating that the tumor KRAS gene status is highly predictive of outcome with anti-EGFR agents, such as cetuximab (Erbitux) and panitumumab (Vectibix). Furthermore, the NCCN guidelines recommend against the use of these agents for patients with tumors characterized by specific KRAS gene mutations.

The updated NCCN guidelines reflect other new data regarding the use of cetuximab in the treatment of patients with metastatic colorectal cancer, and now include it in combination with specific chemotherapy drugs as a first-line therapy option.

Also new to the NCCN guidelines for colon and rectal cancers are recommendations for the reevaluation of patients with initially unresectable metastatic colorectal disease to determine if they would be suitable for resection following chemotherapy.

Breast Cancer Updates
Notable diagnostic additions to the NCCN breast cancer guidelines include a recommendation for genetic counseling if the patient is at high risk for hereditary breast cancer, as well as six new recommendations detailing when magnetic resonance imaging (MRI) may be helpful in breast cancer evaluations.

Conversely, the updated NCCN breast cancer guidelines state that positron- emission tomography/computed tomography (PET/CT) scanning is not recommended for evaluation of newly diagnosed patients with early-stage disease except in clinical situations where other staging studies are equivocal or suspicious, and even in these situations that biopsy is recommended. The NCCN guideline panel members note that although there is limited evidence demonstrating the utility of PET/CT scan in the staging of patients, they consider biopsy to be more likely to provide useful staging information.

Significant additions were also made to the portion of the NCCN guidelines providing recommendations for patients undergoing breast reconstruction following surgery. It is now recommended that women receive an evaluation detailing the likely cosmetic outcome of a lumpectomy prior to the actual surgery. Furthermore, women who are not satisfied with the cosmetic outcome following completion of breast cancer treatment should be offered a plastic surgery consultation.

Notable additions to the NCCN guidelines for breast cancer risk reduction include updates to two risk-reduction agents, tamoxifen and raloxifene (Evista). Tamoxifen is recommended for premenopausal women with a history of atypical hyperplasia to reduce breast cancer risk. For postmenopausal women, raloxifene is listed as equivalent to tamoxifen in reducing the risk of developing invasive breast cancer; however, it did not provide the same level of risk reduction for developing noninvasive breast cancer.