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.