The National Comprehensive Cancer Network has issued new Clinical Practice Guidelines for Adolescents and Young Adults (AYA) with cancer, as well as for acute lymphoblastic leukemia (ALL). Both guidelines were released last month at the organization's Annual Conference on Clinical Practice Guidelines & Quality Cancer Care.
Presenting the AYA guidelines, Panel Chair Peter F. Coccia, MD, of Eppley Cancer Center noted that patients in this age group have better outcomes when treated with aggressive therapies utilized by pediatric oncologists.
"We also see worse outcomes for AYA patients diagnosed with adult-onset cancers such as breast and colon cancer. There is an urgent need for increased awareness of the many unique issues responsible for these poor outcomes in the AYA oncology patients."
The guidelines strongly advise AYA patients to be treated at cancer centers with specific expertise in treating that age group and cancer type. Also emphasized is the need for a more multidisciplinary approach, and that caregivers need to pay more attention to these patients' physical and psychosocial issues.
"These patients face serious problems related to loss of fertility, disruptions in their education or their careers, and their social interactions-in addition to the threat to their mortality," said Panel member Bradley J. Zebrack, PhD, MSW, MPH, of the University of Michigan Comprehensive Cancer Center. "These issues, and the isolation that accompanies them, can affect their lives for many years."
First NCCN Guidelines Ever for ALL
The new guidelines for acute lymphoblastic leukemia are the organization's first for that cancer.
"We felt it was very important to develop a clear standard of treatment for adult ALL," said Panel Co-Chair Patrick A. Brown, MD, Director of the Pediatric Leukemia Program, at Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins.
"We now have consistent data that young adults with ALL benefit significantly from treatments inspired by those used for children with ALL. Younger adults can tolerate the intensive therapies that we use for our pediatric patients, and this translates into better outcomes."
He noted that there was considerable discussion between his group and the AYA panel. Both guidelines emphasize the importance of providing expert, comprehensive supportive care and increasing the enrollment of young adult patients into clinical trials.
The guidelines also address treatment for older ALL patients, who are often more difficult to treat successfully than younger patients, due often to the higher frequency of poor-risk cytogenetic abnormalities observed among older adults with ALL, such as the translocation that results in the Philadelphia chromosome, which leads to the formation of the BCR-ABL fusion gene.
The guidelines call for initially stratifying all patients based on that abnormality, as well as whether or not they have minimal residual disease, since those factors are key to treatment options such as BCR-ABL-targeting tyrosine kinase inhibitors and allogeneic stem cell transplantation (SCT).
The other Co-Chair of the ALL Panel, Joseph C. Alvarnas, MD, Director of Medical Quality and Associate Director of the Division of Hematology and Hematopoietic Cell Transplantation at City of Hope Comprehensive Cancer Center, noted that older adult patients may not be appropriate candidates for SCT or intensive therapy options.
Also, in older adults, the presence of comorbid factors limits the use of intensive regimens.
Brown pointed to the emergence of novel immune-based therapies as offering new hope for increased remission rates and longer disease-free survival in older ALL patients.
And both he and Alvarnas emphasized the need for adequate central nervous system-directed treatment to prevent CNS relapse, as well as the importance of comprehensive supportive care measures tailored to the needs of each patient.
"ALL is the rarest form of leukemia in adults," Brown said. "Its treatment poses many challenges and requires expertise and experience in a number of medical disciplines and supportive care areas. We recommend that ALL patients be referred to specialized treatment centers, and if possible, enrolled on clinical trials."
All NCCN guidelines are available for free at NCCN.org