Journal of the National Comprehensive Cancer Network. NCCN News. NCCN Imaging Appropriate Use Criteria Published for 15 Additional Guidelines

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1 xxviii Journal of the National Comprehensive Cancer Network NCCN Imaging Appropriate Use Criteria Published for 15 Additional Guidelines NCCN, a Centers for Medicare & Medicaid Services (CMS) approved provider-led entity for imaging appropriate use criteria (AUC), continues to build its library of AUC and has published NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC) for an additional 15 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Launched in June 2016, NCCN Imaging AUC are now available for 35 NCCN Guidelines. New NCCN Imaging AUC have been published for: Basal Cell Skin Cancer Bone Cancer Breast Cancer Screening and Diagnosis Central Nervous System Cancers Cervical Cancer Colorectal Cancer Screening Dermatofibrosarcoma Protuberans Kidney Cancer Merkel Cell Carcinoma Multiple Myeloma Non Small Cell Lung Cancer Occult Primary (Cancer of Unknown Origin) Squamous Cell Skin Cancer Uterine Cancer Vulvar Cancer NCCN Imaging AUC are an easy-to-use, single source for AUC pertaining to cancer screening, diagnosis, staging, treatment response assessment, follow-up, and surveillance as outlined within the library of NCCN Guidelines. NCCN Imaging AUC include all imaging procedures recommended in the NCCN Guidelines, including radiographs, CT scans, MRI, functional nuclear medicine imaging (PET, SPECT), and ultrasound. NCCN Imaging AUC are available through a Web-based user interface that provides a searchable and user-customized display of approved NCCN Imaging AUC. The complete library of NCCN Imaging AUC is scheduled to be available in The NCCN Guidelines are the recognized standard for clinical policy in cancer care and are often the most thorough and most frequently updated clinical practice guidelines available in any area of medicine. Other NCCN Guidelines derivative products include: The NCCN Drugs & Biologics Compendium (NCCN Compendium), which contains authoritative, scientifically derived information designed to support decision-making about the appropriate use of drugs and biologics in patients with cancer. The NCCN Compendium is recognized by public and private insurers alike, including CMS and UnitedHealthcare, as an authoritative reference for oncology coverage policy. The NCCN Biomarkers Compendium, which contains information designed to support decision-making around the use of biomarker testing in patients with cancer. The NCCN Chemotherapy Order Templates (NCCN Templates), which include chemotherapy, immunotherapy, supportive care agents, doses, schedules, monitoring parameters, and safety instructions for regimens recommended in the NCCN Guidelines. Special instructions for self administered chemotherapeutic agents are also provided.

2 xxix For more information and to access the NCCN Imaging AUC, visit NCCN.org/ ImagingAUC. NCCN Challenges Medical Community to Just Bag It to Eradicate Deadly Medical Error As part of its mission to improve the quality, effectiveness, and efficiency of cancer care so that patients can live better lives, NCCN announced the launch of Just Bag It: The NCCN Campaign for Safe Vincristine Handling. This campaign encourages healthcare providers to adopt a policy to always dilute and administer vincristine in a mini IV-drip bag to prevent a deadly medical error. Vincristine is a chemotherapy agent, widely used in patients with leukemia or lymphoma, which should be administered intravenously, or directly into the patient s vein. When it enters the blood, it is highly effective at blocking the growth of cancer by preventing cells from separating. However, vincristine is a neurotoxin that causes peripheral neuropathy when given intravenously and profound neurotoxicity if given into the spinal fluid, which flows around the spinal cord and brain. Many patients who receive vincristine have a treatment regimen that includes other chemotherapy drugs that are administered intrathecally, or injected into the spinal fluid with a syringe. If vincristine is mistakenly administered into the spinal fluid, it is uniformly fatal, causing ascending paralysis, neurological defects, and eventually death. In 2005, NCCN Chief Executive Officer Robert W. Carlson, MD, a medical oncologist, witnessed such a tragedy with a 21-year-old patient with non-hodgkin s lymphoma named Christopher Wibeto. Wibeto was transferred to Carlson s care after receiving incorrectly administered vincristine at another hospital. Carlson watched the young man go from having a likely curable condition to deteriorating and dying within 4 days. Motivated by this tragic experience, Carlson spearheaded a national effort to address this deadly error when he arrived at NCCN, enlisting the help of its Best Practices Committee, which is dedicated to improving cancer treatment protocols. To ensure that vincristine is always administered properly, NCCN has issued guidelines advising healthcare providers to always dilute and administer vincristine in a mini IV-drip bag and never use a syringe to administer the medication. This precaution renders it impossible to accidentally administer the medication into the spinal fluid and greatly decreases the chances of improper dosage. All 27 NCCN Member Institutions have adopted policies in line with these guidelines, which are also recommended by the Institute for Safe Medication Practices (ISMP), the Joint Commission, the WHO, and the Oncology Nursing Society. We are proud of this achievement and grateful for the support and participation of our member institutions in reaching this goal, Carlson said. Our efforts will not stop here. We challenge all medical centers, hospitals, and oncology practices around the nation and the world to implement this medication safety policy so this error never occurs again. Surveys issued by the ISMP show that over time, more hospitals have adopted a policy to always bag vincristine. According to ISMP data, the number of hospitals that have fully implemented the policy across their practice nearly doubled between February 2014 and February Earlier surveys indicated a similar increase between 2005 and Still, only about half of all respondents indicated that they have implemented the policy in all treatment settings, indicating that there is a long way to go. With 125 known cases of accidental death in the United States and abroad since the inception of vincristine use in the 1960s, this error is relatively rare. Still, it is unique in its level of mortality. Improvements in practice over the years, including Cont. on page xxxii.

3 xxxii Cont. from page xxix. manufacturer- and pharmacist-issued warning labels, have reduced the number of deaths, but the error continues to occur. Diluting vincristine into a mini IV-drip bag may entail a change in practice for some providers, but it is well worth the outcome of avoiding preventable deaths, according to Michael Cohen, RPh, MS, FASHP, President of ISMP. One more life taken is one too many, Cohen said. We are glad an organization of NCCN s influence has stepped up to bring this issue to national attention. Ending this devastating error should be a priority for all of us who care for and advocate on behalf of patients and their families. Some healthcare providers may associate the use of an IV bag with a heightened risk of extravasation, or the leaking of a chemotherapy drug into the tissue surrounding the intravenous administration site. But research shows that the risk of extravasation is extremely low (<.05%) regardless of how vincristine is administered. 1 The Just Bag It campaign is the latest of NCCN s long-standing efforts to improve the safe use of drugs in cancer care, said F. Marc Stewart, MD, Medical Director of the Seattle Cancer Care Alliance, Member of the Fred Hutchinson Cancer Research Center, Professor of Medicine at University of Washington, and Co-Chair of the NCCN Best Practices Committee. For more than 15 years, the Best Practices Committee has worked to ensure the highest standards of safety for patients. In 2008, the Best Practices Committee led the charge for NCCN to begin publishing Chemotherapy Order Templates (NCCN Templates), which detail the most common regimens for many cancers and highlight safety parameters. These resources enable practitioners to standardize patient care, reduce medication errors, and anticipate and manage adverse events. There are more than 1,500 NCCN Templates for 86 cancer types, and they are used by more than 10,000 subscribers. For more information about Just Bag It: The NCCN Campaign for Safe Vincristine Handling, or to report that a medical facility has adopted a vincristine policy, visit Reference 1. ISMP. Death and neurological devastation from intrathecal vinca alkaloids: prepared in syringes = 120; Prepared in minibags = 0. ISMP Medication Safety Alert! 2013;18:3. New NCCN Patient Education Materials Help Patients Combat Nausea and Vomiting; New Patient App Now Available To inform patients about their treatment options and help them combat nausea and vomiting during treatment, NCCN has published the NCCN Guidelines for Patients and NCCN Quick Guide for Nausea and Vomiting. These patient resources the first from NCCN to focus specifically on supportive care are made available through funding from the NCCN Foundation. Approximately 90% of patients receiving highly emetogenic chemotherapy for treatment of cancer experience nausea and vomiting, making it one of the most prominent and feared side effects of cancer treatment. Not only does nausea and vomiting affect quality of life for patients, which can lead to poor compliance to chemotherapy or radiation therapy, but it can have serious effects on a patient s overall health, including severe metabolic imbalances and dehydration. There are, however, a number of prophylactic treatments for nausea and vomiting available to patients, which lower the incidence of nausea and vomiting to 30%. At NCCN, our mission is to improve the lives of patients with cancer, and we are excited to be able to provide the information that will help patients better understand Cont. on page xxxix.

4 xxxix this common side effect of cancer treatment, said Marcie R. Reeder, MPH, Executive Director, NCCN Foundation. The NCCN Guidelines for Patients for Nausea and Vomiting are the first of a highly anticipated library of supportive care resources that provide patients with the same information their doctors use. The patient resources for nausea and vomiting are available on NCCN.org, as well as on the new NCCN patient app. The new app, NCCN Patient Guides for Cancer, is available free of charge for Android and ios devices and features the complete library of NCCN Guidelines for Patients and NCCN Quick Guide sheets. With the launch of the new mobile app, patients and caregivers have easy-tounderstand cancer treatment information at the tips of their fingers. We are excited to deliver this world-class information to all audiences, whether in print, online, or via mobile device, added Ms. Reeder. NCCN Guidelines for Patients, patient-friendly translations of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines), are easy-to-understand resources based on the same clinical practice guidelines used by healthcare professionals around the world to determine the best way to treatment a patient with cancer. Each resource features unbiased expert guidance from the nation s leading cancer centers designed to help people living with cancer talk with their physicians about the best treatment options for their disease. NCCN Guidelines for Patients and NCCN Quick Guide sheets one-page summaries of key points in the patient guidelines are written in plain language and include patient-friendly elements, such as questions to ask your doctor, a glossary of terms, and medical illustrations of anatomy, tests, and treatments. NCCN Guidelines for Patients and NCCN Quick Guide sheets do not replace the expertise and clinical judgment of the clinician. NCCN currently offers NCCN Guidelines for Patients for the following: Breast, Colon, Esophageal, Kidney, Non Small Cell Lung, Ovarian, Pancreatic, Prostate, and Stomach Cancers; Acute Lymphoblastic Leukemia; Adolescents and Young Adults with Cancer; Chronic Lymphocytic Leukemia; Chronic Myelogenous Leukemia; Hodgkin Lymphoma; Lung Cancer Screening; Malignant Pleural Mesothelioma; Melanoma; Multiple Myeloma; Nausea and Vomiting; Non-Hodgkin s Lymphomas; and Soft Tissue Sarcoma. The NCCN Guidelines for Patients and NCCN Quick Guide sheet for Nausea and Vomiting are available to download for free from NCCN.org/patients and on the NCCN Patient Guides for Cancer mobile app. Cont. from page xxxii. NCCN Chemotherapy Order Templates to be Integrated into Cerner s Electronic Health Record NCCN is collaborating with Cerner to integrate the NCCN Chemotherapy Order Templates (NCCN Templates) into PowerChart Oncology, the oncology-specific solution within Cerner s electronic health record (EHR), as electronic chemotherapy protocols for use by healthcare providers. NCCN Templates will be available for PowerChart Oncology users in We are collaborating with Cerner to provide practitioners with access to evidence-based treatment protocols at the point of care to help provide patients with the most up-to-date regimens possible for their specific diagnoses, said Dr. Robert W. Carlson, CEO, NCCN. As part of the integration, Cerner s EHR will link to NCCN.org, providing end-user access to NCCN Templates and the corresponding NCCN Guidelines, helping practitioners make treatment decisions based on up-to-date, evidence-based standard protocols. At Cerner, we constantly work to provide solutions that support the oncology care team as they make the best treatment decisions possible. Our collaboration

5 xl with NCCN will further this mission by providing clinicians with direct access to the evidence-based NCCN Chemotherapy Order Templates in their PowerChart Oncology workflow, said Susan Stiles, Oncology solution executive at Cerner. We have always recommended that clients use NCCN Guidelines and NCCN Templates and now they will be integrated into PowerChart Oncology. This will help providers follow the most up-to-date treatment plans and be more available to focus on what is most important, their patients. The information contained in the NCCN Templates is based on the NCCN Guidelines. NCCN Templates include chemotherapy and immunotherapy regimens with literature support, supportive care agents, monitoring parameters, and safety instructions. A goal of the NCCN Templates is to enhance patient safety by empowering healthcare providers to standardize patient care, reduce medical errors, and anticipate and manage adverse events. NCCN continues to expand the library of chemotherapy order templates to work toward improved safe and effective use of drugs and biologics in cancer care. For more information about NCCN Templates, visit NCCN.org/templates.