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Conference Coverage: NCCN
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Conference Coverage: NCCN

Surabhi Dangi-Garimella, PhD, and Christina Mattina
A roundup of the panels and sessions at the National Comprehensive Cancer Network's 22nd Annual Conference: Improving the Quality, Effectiveness, and Efficiency of Cancer Care, held March 23-25, 2017, Oralndo, Florida.
Helping Cancer Patients Quit Smoking Through Counseling and Pharmacotherapy

Christina Mattina

At the 22nd Annual Conference of the National Comprehensive Cancer Network (NCCN), in Orlando, Florida, Paul M. Cinciripini, PhD, of The University of Texas MD Anderson Cancer Center, delivered a presentation on a mission he said he has spent the better part of his life working on: getting patients with cancer to quit smoking cigarettes.

Cinciripini, who serves as professor and chair for the Department of Behavioral Science as well as director of the Tobacco Treatment Program at MD Anderson, acknowledged that the audience of mainly oncologists did not need to be convinced that smoking is harmful. He discussed data which indicate over 480,000 deaths per year in the United States are attributable to cigarette smoking, and summarized the beneficial effects of cessation, including reduced depression, anxiety, and stress, along with improved positive mood and quality of life (QOL).

These outcomes, both the dangers of smoking and the benefits of cessation, are magnified in cancer patients, Cinciripini explained. Smoking during cancer treatment is associated with an increased risk of recurrence, greater symptom burden, and reduced survival. Response to radiotherapy is diminished in smokers, and they have an increased risk of pulmonary embolism, infection, and poor wound healing. Smokers also experience worsened toxicities and immune impairment while undergoing chemotherapy, and the efficacy of the treatment is diminished.

In one study, patients who quit smoking had a 78% overall survival rate 2 years after radiotherapy compared with 69% among those who continued to smoke. From a QOL perspective, cancer patients who quit smoking report easier breathing and a boost in energy. Clearly, Cinciripini said, there is a need for intervention among this population.

The most effective interventions, he explained, involve a combination of counseling and medications. Recommended first-line medications include varenicline, bupropion, and nicotine-replacement therapies like patches or gum. Cinciripini cited the EAGLES trial that found varenicline to be more effective than bupropion, nicotine patch, or placebo in patients with and without psychiatric disorders. The occurrence of severe neuropsychiatric events during treatment, including suicide, was similar across all tested therapies. Cinciripini nonetheless advised clinicians to think about the patient’s psychiatric background and history when prescribing these treatments, and to “be on the lookout for any untoward changes in their psychiatric profile.”

He then highlighted several studies demonstrating better cessation rates associated with higher intensity counseling, defined as more than 4 sessions lasting 30 to 300 minutes, compared with minimal intensity counseling. Although this more intense treatment costs more, Cinciripini explained that its increased effectiveness makes it more cost-effective. He also cited research that found a combination of intense counseling plus the introduction of nicotine replacement therapy before quitting was more effective at 16 and 26 weeks than either intervention alone.

After presenting this literature, Cinciripini discussed the NCCN clinical guidelines for smoking cessation in oncology. First, clinicians must assess patients’ nicotine dependency, history of quit attempts, and readiness to quit. If a patient is ready to quit, the clinician should involve him or her in establishing a plan and setting a quit date. If he or she is not ready, the clinician can help address concerns and suggest pharmacotherapy to reduce the number of cigarettes smoked per day. The goal of this reduction is eventually quitting, Cinciripini emphasized, not just harm reduction.

The primary recommended therapies are a combination of behavioral therapy and either nicotine replacement therapies or varenicline. If a patient succeeds in quitting, the guidelines recommend “motivational strategies for continued abstinence.” If a patient relapses, clinicians can switch the type of therapy, but must be sure to maintain consistent engagement with the patient.

Smoking cessation is “not a one and done” event, Cinciripini emphasized, and requires consistent contact and follow-up by the clinician. “If they quit, great, stay engaged. If they don’t, great, stay engaged,” he summarized. When the audience was invited to ask questions, an attendee asked Cinciripini his opinion on e-cigarettes as a form of risk mitigation, although he’d previously said he was focusing on complete cessation, not harm reduction.

“I knew I was going to get that question,” Cinciripini sighed jokingly. “The answer is, it depends.”

While there isn’t enough data to establish effectiveness and long-term safety for the devices, he said, the reduction in carcinogens makes it preferable to cigarettes and can provide an opening for patients to transition toward eliminating nicotine. Cinciripini said he would not rule out e-cigarettes as a potential tool if researchers had more data, but reiterated he was “most comfortable talking about valid nicotine therapies” as a means for cessation.

Radiation Therapy Updates for Breast Cancer in the NCCN Guidelines

Surabhi Dangi-Garimella, PhD

On the second day of the 22nd Annual Conference of the National Comprehensive Cancer Network (NCCN), in Orlando, Florida, Kilian E. Salerno, MD, of the Roswell Park Cancer Institute, walked the audience through updates to the NCCN Guidelines, explaining clinical situations in which radiation is indicated, appropriate targets of radiation treatment, and optimal approaches for minimizing toxicity.

Understanding the target area is important, Salerno said, because the treatment options and the treatment plan and delivery need to be optimized per the patient’s needs. “The target region to receive the radiation dose can vary. It might be the whole breast; partial breast, where we may target the lumpectomy cavity; the chest wall; or just regional nodes.”

The dose varies according to the target region:

1. Conventional fractionation is a dose of 1.8 to 2 Gy per fraction, for a total dose of 45 to 50.4 Gy.

2. Hypofractionation is typically a shorter course that uses larger doses per fraction. More than 2 Gy may be used per fraction to lower the total dose, which can be:

  • 40.05 to 42.56 Gy given in daily fractions for whole breast radiation
  • 34-38.5 Gy administered as twice daily fractions for partial breast radiation
3. The accelerated course is usually treatment over a shorter time course. Clinics have several options for the source of radiation to choose from, Salerno said. The sources of radiation include:
  • External beam (photons, electrons, proton beam)
  • Brachytherapy (radioactive source or catheters)
  • Intraoperative devices
The NCCN Guidelines for breast cancer, updated in March 2017,1 provide guidance on target definition and optimizing therapy for an individual patient as needed. “Greater target dose homogeneity and sparing of normal tissues can be accomplished using compensators such as wedges, forward planning using segments, and intensity-modulated radiation therapy,” the guidelines stated.

The most commonly used techniques include:
  • Positioning: supine versus prone. Salerno said that the prone position is used to identify hot spots and minimize damage to normal tissue. It is most typically used for early-stage disease when the whole breast is the target, and it ensures the normal tissue is not affected.
  • Computed tomography for based planning
  • Three dimensionally planned conformal radiotherapy versus immune-modulated radiation therapy
  • Respiratory gating, where the patient controls respiration. This technique requires extra time, personnel, planning, and time for treatment, Salerno said.
The updated guidelines also provide information on patients who have undergone breast conservation but in whom radiation therapy is contraindicated.

An absolute “No” includes:
  • Pregnancy
  • Diffuse suspicious or malignant-appearing microcalcifications
  • Diffusely positive pathologic margins
  • Homozygous for ATM mutations
Relative contraindication in case of:
  • Prior radiation therapy to the chest wall or breast
  • Active connective tissue disease that involves the skin
  • Tumors larger than 5 cm
  • Positive pathologic margins
  • Women with a suspected predisposition to breast cancer
“Identifying an appropriate margin has been a topic of debate, and the new Guideline provides direction,” said Salerno. “We must remember, though, that context matters.” The following 2 recommendations have been added to the Guideline:
  • 2 mm is considered an adequate margin2 in ductal carcinoma in situ treated with whole-breast irradiation.
  • For stage I-II invasive disease treated with whole-breast irradiation, no tumor on ink is considered an adequate margin.
Salerno then spoke about locoregional treatment of clinical stage I, IIA, or IIIB disease or node-positive disease. For negative axillary nodes, the following treatment options have been recommended:
  • Radiation therapy to the whole breast, with or without boost to the tumor bed; preferably hypofractionation
  • Accelerated partial breast irradiation in some low-risk patients, following guidelines defined by the American Society of Radiation Oncology, which, Salerno said, will be updated in the coming year.
She then provided insight on post-mastectomy radiation (PMRT), classic indications for which include 4 or more positive axillary lymph nodes, positive margins, and tumor size over 5 cm. However, patients with 1 to 3 lymph nodes, close margins and some high-risk features, such as age, extracapsular extension, and certain intrinsic subtypes, could also be considered for PMRT.

Regional node irradiation or RNI is recommended for those with 4 or more positive nodes, strongly considered for 1 to 3 positive nodes, and may be considered for some high-risk node negative patients.

REFERENCES

1. NCCN Guidelines for treatment of cancer by site. National Comprehensive Cancer Network website. https://www. nccn.org/professionals/physician_gls/f_guidelines.asp. Accessed March 24, 2017.

2. Morrow M, Van Zee KJ, Solin LJ, et al. Society of Surgical Oncology–American Society for Radiation Oncology–American Society of Clinical Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in ductal carcinoma in situ. J Clin Oncol. 2016;34(33):4040-4046. doi: 10.1200/JCO.2016.68.3573.

Personalized Care in Lung Cancer Is All About the Molecular Subtype

Surabhi Dangi-Garimella, PhD

At the 22nd Annual Conference of the National Comprehensive Cancer Network (NCCN), held in Orlando, Florida, Gregory J. Riely, MD, PhD, Memorial Sloan Kettering Cancer Center, spoke about the what, when, and how of biomarker testing in non–small cell lung cancer.

Biomarker testing is essential in lung cancer, Riely said, and should be done at diagnosis. “Even if it is not done at diagnosis, testing before the choice of second-line therapy is valuable as well.”

 
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