FORT LAUDERDALE, Fla--The National Comprehensive Cancer Network
(NCCN) unveiled preliminary clinical practice guidelines for eight
diseases at its first annual conference (see photograph below).
The network now includes 14 institutions nationwide with the addition
of its newest member, Roswell Park Cancer Institute.
In an interview, Stanford University's Robert Carlson, MD, chair
of the breast cancer panel, said that "there was remarkable
agreement among our committee in nearly all aspects of the guidelines."
He cited two primary areas of controversy.
In the committee's initial draft, routine chest x-rays were not
included in the follow-up of patients after adjuvant chemotherapy.
"However, there was a ground swell from people external to
the committee that made it clear to us that the guidelines had
to include routine surveillance chest x-rays."
The other topic of greatest discussion was whether to include
high-dose intensive chemotherapy with bone marrow/stem cell support
in the guidelines as a routine treatment, an issue that pitted
what Dr. Carlson called "disease-oriented specialists"
against "modality-oriented specialists."
"The committee felt, without exception, that high-dose intensive
therapy was investigational," he said. Consequently, in a
footnote to the breast cancer guidelines, the committee stated
that "based on current evidence and NCCN expertise, dose-intensive
chemotherapy is not appropriate outside the confines of an appropriately
designed, peer-reviewed prospective clinical trial." Peer
review in this context includes formal NCI review or NCCN institutional
sci,entific review committees.
Dr. Carlson called the footnote "a positive statement signifying
that we need more information regarding high-dose intense therapy;
we certainly encourage participation in clinical trials."
At the meeting, Dr. Carlson asked the audience for a show of hands
as to whether dose-intensive chemotherapy should be restricted
to clinical trials or included in the guidelines for use in high-risk
patients (10 or more positive nodes) or patients with responding
metastatic disease in first relapse.