Treatment Algithm: Multiple Myeloma This algithm applies to the majity of patients but may not be applicable to every patient. Patients should be enrolled in clinical trials if possible at all stages, even if it results in deviation from the algithm Renal failure? (Creatinine elevated dialysis dependent) Consider entry into clinical trial Dexamethasone Creatinine remains elevated remains dialysis dependent? Consider age / PS etc fit f high dose treatment? Proteosome inhibit, e.g. Btezomib + Dexamethasone, Thalidomide + steroid based therapy (6-9 cycles) until plateau/cr CTD (x 4-9) + Bisphosphonate Plateau High dose Melphalan + PBSCT Plateau / CR CTD (x 6-9) + Bisphosphonate Plateau / CR Proteosome inhibit, e.g. Btezomib + Dexamethasone if not previously used * Plateau / CR Relapse / progression Lenalidomide/IMID + Dexamethasone Intolerant stable / progressive disease Consider further Lenalidomide/ IMID + Dexamethasone if previously responsive Btezomib + Dexamethasone * Plateau / CR Consideration of 2 nd PBSCT at MDT (eligible if > 12 months response with 1 st autograft) Plateau / CR Select salvage regimen based on Combidities and residual toxicities from previous treatment Consider entry into clinical trial Proteosome inhibit, eg. Btezomib + Dexamethasone * Plateau / CR Intolerant stable / progressive disease * If patient is unsuitable f Proteosome inhibit, e.g. Btezomib, treat as follows: Unsuitable due to peripheral neuropathy Lenalidomide/ IMID / dexamethasone Unsuitable due to po venous access / other patient fact repeat Thalidomide-based regime Lenalidomide / IMID if previous po response / sht remission with CTD If patient intolerant Thalidomide contraindicated consider Proteosome inhibit containing regime eg. VMP, cybdex Page 1 of 10
Treatment Algithm: AML (Acute Myeloid Leukaemia) Exclude APML. Start supptive care, tumour lysis protocol, fertility considerations as applicable. Consider Cyteduction treatment with Hydroxycarbamide Fit f intensive therapy t fit f intensive therapy Induction with ADE DA similar Supptive care +/- s/c Cytarabine Hydroxycarbamide Consider Azacitidine (when 20-30% blasts) as per NICE Risk assessment (after 1st cycle) CR Refracty / no response Consider BMT Consolidation with: DA ADE ARA-C FLAG-ida FLAG +/- Ida, Clofarbine if previously ADE DA Consider BMT *** SEE SEPARATE ALGORITHM FOR APML *** Relapse (Refer to) tertiary centre This algithm applies to the majity of patients but may not be applicable to every patient. Patients should be enrolled in clinical trials if possible at all stages, even if it results in deviation from the algithm Page 2 of 10
Treatment Algithm: ALL (Acute Lymphoblastic Leukaemia) Start supptive care, tumour lysis protocol, fertility considerations as applicable. Consider Cyteduction treatment with steroids Patient fit f intensive chemotherapy Patient not fit f intensive chemotherapy Induction chemotherapy as per UKALL protocols (14 and 2011) including Tyrosine Kinase inhibits in Philadelphia positive patients Ph positive Ph negative Remission Continue on protocol. Consider allogeneic stem cell transplantation. Refracty Fit f salvage chemotherapy? Supptive care +/- Tyrosine Kinase inhibit +/- Cyteductive chemotherapy (e.g. Vincristine, +/- Prednisolone, 6MP) Supptive care +/- Cticosteroids +/- Vincristine +/- maintenance Remission Reinduction (e.g. FLAG+/-Ida, ALLR3, Clofarabine) Refracty This algithm applies to the majity of patients but may not be applicable to every patient. Patients should be enrolled in clinical trials if possible at all stages, even if it results in deviation from the algithm Page 3 of 10
Treatment Algithm: DLBCL (Diffuse Large B-Cell Lymphoma) Staging and decision to treat Fit f aggressive treatment t fit f aggressive treatment Stage IA CHOP +/- rituximab (may require CDF) x 3-4 cycles followed by involved field RT CD20 positive stage II / III / IV CHOP-R x 6-8 cycles Consider intrathecal methotrexate f high risk CNS disease. Best supptive care which may include radiotherapy +/- palliative al chemotherapy (e.g. PEP-C) Reduced intensity chemotherapy (e.g. R-mini-CHOP, R-GemCVP, R-CVP) High dose methexate may be appropriate f highest risk patients. There may be a role f RT as consolidation f certain patients post chemotherapy Relapse / refracty Discuss at MDT f salvage regimen and/ referral to tertiary centre. Consider the following salvage regimens: Mini-BEAM, ESHAP, DHAP, IVE. Rituximab can be added in f late relapse (> 6 months f previous rituximab) but may require CDF. F me palliative patients, options may include radiotherapy, gemcitabine palliative al chemotherapy such as PEP-C This algithm applies to the majity of patients but may not be applicable to every patient. Patients should be enrolled in clinical trials if possible at all stages, even if it results in deviation from the algithm Surrey, West Sussex and Hampshire Cancer Netwk. Chemotherapy Algithm f Diffuse Large B-Cell Lymphoma. October 2011. Thames Valley Cancer Netwk. Best possible practice follicular lymphoma and other indolent lymphomas and diffuse large B-cell lymphoma cancer care pathway. June 2010. Page 4 of 10
Treatment Algithm: Follicular Lymphoma Staging and investigations Asymptomatic advanced stage Stage I / II Symptomatic advanced stage II (certain patients) / III / IV Grade 3 disease Watch and wait Symptoms progression Involved field RT, although may not be required if complete surgical excision Rituximab + CVP / CHOP / bendamustine (CDF) / chlambucil 6-8 cycles of chemotherapy, 8 cycles of rituximab Treat as per DLBCL algithm Rituximab maintenance given 2- monthly f 2 years Relapse on maintenance / refracty Relapse post maintenance Further R- chemotherapy F patients in remission following chemotherapy, maintenance rituximab given 3- monthly Discuss at MDT f consideration of salvage therapy. Options include CHOP, fludarabine, bendamustine with stem cell transplantation f appropriate responding patients. This algithm applies to the majity of patients but may not be applicable to every patient. Patients should be enrolled in clinical trials if possible at all stages, even if it results in deviation from the Surrey, West Sussex and Hampshire Cancer Netwk. Chemotherapy Algithm f Follicular Lymphoma. October 2011. Thames Valley Cancer Netwk. Best possible practice follicular lymphoma and other indolent lymphomas and diffuse large B-cell lymphoma cancer care pathway. June 2010. Page 5 of 10
Treatment Algithm: Hodgkins Lymphoma Diagnosis and staging, discussion at MDT Classical HL dular lymphocyte predominant HL Stage I / II Stage II bulky / III / IV Radiotherapy +/- immunochemo Watch and wait ABVD chemotherapy +/- radiotherapy ABVD, ChlVPP escbeacopp chemotherapy Symptoms progression Remission Repeat staging progression Follow up as appropriate f up to 5 years Salvage chemotherapy, options include Gem/Cis, DHAP, ESHAP, IVE +/- RT Possible relapse Consider lymph node / tissue biopsy Confirmed relapse / refracty disease response, consider alternative salvage If respond, autograft if appropriate Relapse post autograft no response to 2 salvage regimens consider brentuximab (CDF) Supptive and palliative care (may include palliative RT / chemotherapy e.g. gemcitibine, vinblastine etc.) response F responding patients, consider allogenic stem cell transplantation This algithm applies to the majity of patients but may not be applicable to every patient. Patients should be enrolled in clinical trials if possible at all stages, even if it results in deviation from the algithm Thames Valley Cancer Netwk. Best possible practice Hodgkin lymphoma cancer care pathway. June 2010. Page 6 of 10
Treatment Algithm: MCL (Mantle Cell Lymphoma) Clinically benign and asymptomatic? Watch and wait Fitter patients who may be transplant candidates Less fit Frail, not fit f CHOP-R CHOP-R x 6-8 cycles Consider rdic II, maxi-chop-r, cyatarabine, autograft Rituximab maintenance 2 monthly (CDF) Options include: s/c cytarabine, alkylating agent, bendamustine (CDF) steroids, best supptive care Relapse post autograft. Consider salvage therapy (R-chemotherapy). If patient responds and is fit, may be a candidate f allogeneic transplant Relapse post first line chemotherapy and fit f further chemotherapy, consider R-bendamustine (CDF) Further relapse, consider palliative chemotherapy e.g. PEP-C, btezomib (CDF), palliative RT This algithm applies to the majity of patients but may not be applicable to every patient. Patients should be enrolled in clinical trials if possible at all stages, even if it results in deviation from the algithm rfolk and rwich University Hospital NHS Foundation Trust. Disease Management Pathway f Mantle Cell Lymphoma. May 2012. Page 7 of 10
Treatment Algithm: APML (Acute Promyelocytic Leukaemia) Induction with Idarubicin and ATRA (AIDA regime) Mphological CR Consolidation x 3 (AIDA) Idarubicin and ATRA : Mitoxantrone and ATRA Idarubicin and ATRA High risk/ Relapse Ongoing 3-monthly MRD moniting where appropriate Discuss with tertiary centre Arsenic-based therapy This algithm applies to the majity of patients but may not be applicable to every patient. Patients should be enrolled in clinical trials if possible at all stages, even if it results in deviation from the algithm rth West London Cancer Netwk. Guidelines f the management of adult acute leukaemia. February 2012. Surrey, West Sussex and Hampshire Cancer Netwk. Chemotherapy Algithm f Acute Myeloid Leukaemia. October 2011. Page 8 of 10
Anglia Cancer Netwk Treatment Algithm: Chronic Lymphocytic Leukaemia Does patient require therapy (as per IWCLL criteria)? Watchful waiting Disease progression Consider FISH panel testing f those fit f intensive treatment t fit f intensive treatment If p53 deleted / mutated, alemtuzumab and/ cticosteroids (used as monotherapy, combination sequential) Treatment options include FCR, bendamustine + rituximab may be appropriate f very specific patients (CDF) Consider bendamustine, chlambucil +/- steroids / RT if appropriate Refer responders f consideration of allogenic BMT Relapse after long response FISH reassessment. If p53 deleted / mutated, alemtuzumab and/ cticosteroids If p53 wild-type consider retreatment with same alternative first line therapy / Sht response If patient is allograft candidate, consider alemtuzumab Relapse consider palliative retreatment (eg chlambucil +/- RT etc) Allogenic BMT F second remission patients, consider allograft if appropriate Patient unsuitable f intensive treatment Suppt & palliative care This algithm applies to the majity of patients but may not be applicable to every patient. Patients should be enrolled in clinical trials if possible at all stages, even if it results in deviation from the algithm Surrey, West Sussex and Hampshire Cancer Netwk. Chemotherapy Algithm f CLL/SLL. October 2011. Thames Valley Cancer Netwk. Best possible practice chronic leukaemia cancer care pathway. June 2010. Page 9 of 10
Document management Document ratification and histy Approved by: Kristian Bowles Date approved: 25 January 2013 Date placed on electronic library: Apr 13 Review date: One year Myeloma Martin Auger, Consultant Haematologist, NNUH Jenny Craig, Consultant AML, ALL Jenny Craig, Consultant Matthew Lawes, Consultant Haematologist, NNUH Auths: CLL Gege Follows, Consultant DLBCL Gege Follows, Consultant Document Owner: Anglia Cancer Netwk Tel: 01638 558580 http://www.angcn.nhs.uk/ Follicular Lymphoma/Hodgkins Lymphoma Gege Follows, Consultant Mantle Cell Gege Follows, Consultant APML Jenny Craig, Consultant Version number as approved and published: 2 Unique identifier no.: AngCN-CCG-C38 Moniting the effectiveness of the Process a) Process f Moniting compliance and Effectiveness - Review of compliance as determined by audit. Any non-compliance to be presented by PQ Manager to the AngCN Business Meeting on an annual basis the minutes of this meeting are retained f a minimum of five years. b) Standards/Key Perfmance Indicats This process fms part of a quality system wking to, but not accredited to, International Standard BS EN ISO 9001:2008. The effectiveness of the process will be monited in accdance with the methods given in the quality manual, AngCN-QM. Equality and Diversity Statement This document complies with the Suffolk PCT Equality and Diversity statement an EIA assessment is available on request to Anglia Cancer Netwk PQ Manager, Gibson Centre, Exning Road, Newmarket, CB8 7JG. Disclaimer It is your responsibility to check against the electronic library that this printed out copy is the most recent issue of this document. Please notify any changes required to the Anglia Cancer Netwk PQ Manager. Page 10 of 10