NCCN ovarian cancer guidelines updated

Guidelines include new information on allergic reactions to treatment and pemetrexed use.

Newly revised guidelines issued by the National Comprehensive Cancer Network include for the first time recommendations for dealing with platinum-related allergies and a section on applying trial results to clinical practice for patients with ovarian cancer.

Robert J. Morgan, MD, chair of the NCCN guidelines for ovarian cancer committee and a professor of medical oncology and therapeutics research with City of Hope in Duarte, Calif., discussed the new guidelines with HemOnc Today. He said the revisions included updates to the principals of staging and surgery, the addition of pemetrexed (Alimta, Eli Lilly) as a potential therapy for recurrent disease and changes to the germ cell cancer algorithm.

In addition, there is information on “a protocol for dealing with platinum or other chemotherapy allergies and a physician’s statement on principles of chemotherapy,” Morgan said.

Treating allergies

Morgan said physicians have recognized during the past few years that an increasing number of patients are developing delayed allergies to platinum-based chemotherapy. Research by Marianna C. Castells, MD, PhD, and committee members Maurie Markman, MD, and Ursula Matulonis, MD, into desensitizing patients to platinum-based chemotherapy played a role in developing the new guidelines.

The protocols include signs and symptoms of infusion reactions, preparations for potential reactions and advice for dealing with allergies once they occur. The committee recommends administering small doses of medication during four to 13 hours to avoid allergic reactions.

“Unlike other illnesses where people develop a resistance to a drug and never receive it again, ovarian cancer patients will often receive platinum-based chemotherapy a second, third or even fourth time depending on their overall treatment course,” Morgan said. “Because platinum drugs are still the most important agents for the treatment of ovarian cancer, it’s become important to be able to figure out if there’s a strategy to learn whether patients who have an allergy will be able to be retreated.”

Principles of chemotherapy

In the principles of chemotherapy section, NCCN encourages patients with cancer to participate in clinical trials “during all aspects of their diagnosis and treatment” and reminds physicians that they should make sure patients are aware of the various treatment options available and the associated potential adverse effects. Morgan said the committee developed the principles of chemotherapy in part to remind physicians that patients in the clinic may not reflect patients in trials.

“When we publish the clinical trials, we are publishing our results based on that cohort of patients recruited to the trial. That includes dosing, potential adverse effects and effectiveness,” he said. “The problem is that, once the paper is published, patients may be treated at those same doses and on those same regimens, and they may not fit the original descriptions of the patients who were enrolled on those clinical trials.

“We’re tying to alert physicians and patients that we really do think most patients with ovarian cancer should be on clinical trials, but we also want them to be aware that dose schedules and modifications may need to be adjusted based on the individual patient’s situation.”

He said that based on recent publications that suggested intraperitoneal chemotherapy can be of substantial benefit in patients who have optimally debulked ovarian cancer, the committee wanted to advise physicians that they should discuss intraperitoneal chemotherapy and IV chemotherapy as a treatment option.

Morgan said the committee chose to add pemetrexed, first used to treat lung cancer and mesothelioma, to the preferred list of cytotoxic agents because of newly published research that suggested the drug is active both alone and in combination against recurrent ovarian cancer. An estimated 75% to 80% of patients with advanced ovarian cancer will experience recurrence at some point.

“The guideline changes indicate that we are making advances in the surgical and chemotherapeutic management of ovarian cancer, which are making the treatment course more tolerable,” Morgan said. “Surgical advances, including minimally invasive surgery, allow fewer complications, and chemotherapeutic advances are allowing more options in primary and recurrence management.” – by Jason Harris