Testing Guidelines at a Glance

The American Society of Clinical Oncology (ASCO) published updated practice guidelines Aug. 14 in the Journal of Clinical Oncology regarding the use of targeted immunotherapy for patients with stage IV non–small-cell lung cancer. The recommendations, an update from those published in 2015, are based on a systematic review of 14 randomized controlled trials conducted from February 2014 to December 2016, and focus on EGFR, ALK, and ROS1 alterations, as well as PD-L1 expression.

• The immunotherapy drug pembrolizumab is recommended as a first-line treatment in patients who don’t have sensitizing EGFR mutations, ALK rearrangements, or ROS1 rearrangements, but who have high PD-L1 expression. For patients with low PD-L1 expression, clinicians should use standard chemotherapy.

• Despite recommending different treatments based on PD-L1 status, the guideline update does not direct physicians to use a specific PD-L1 assay or test, nor does it delineate a cutoff point for what it considers high or low PD-L1 expression.

• The guidelines maintain the 2015 recommended use of first-line targeted treatment with EGFR mutationpositive, ALK rearrangement-positive, or ROS1 rearrangement-positive tumors.

In July, ASCO also provided a focused update recommending the use of the MammaPrint (Agendia; Irvine, Calif.) multigene panel to help guide decisions on the use of adjuvant systemic therapy for women with early-stage breast cancer. The recommendations update ASCO’s 2016 clinical practice guideline on the use of biomarkers in these patients. The focused update was the result of the 2016 study from a randomized phase III clinical trial of the MammaPrint gene test. Specifically, ASCO recommends the use of the test in patients with hormone receptor–positive, human epidermal growth factor receptor 2 (HER2)–negative, node-negative breast cancer to inform decisions on withholding adjuvant systemic chemotherapy. ASCO says MammaPrint is able to to identify a good-prognosis population with potentially limited chemotherapy benefit.

American Association for Cancer Research
The American Association for Cancer Research (AACR) published its first set of consensus screening recommendations for children with common cancer predisposition syndromes. The CCR Pediatric Oncology Series, published in June and July in Clinical Cancer Research, sought to develop recommendations for primary and specialty pediatric clinicians for the management of children at significant hereditary risk for cancer, but who have not yet developed their first cancer.

Pediatric Cancer Working Group of the AACR convened a workshop that included 65 professionals. The group reviewed existing data and practices, and established recommendations for cancer surveillance for the 50 most common syndromes that predispose children to cancer. These syndromes were clustered into nine major groups based on the major cancer types (Li-Fraumeni syndrome, neurofibromatoses, overgrowth syndromes and Wilms tumor, neural tumors, GI cancer predisposition, neuroendocrine syndromes, leukemia predisposition, DNA instability syndromes, and miscellaneous syndromes).

The group developed 18 position papers that provide recommendations for surveillance, focusing on when to initiate or discontinue specific screening measures, which modalities to use, and how frequent to screen patients. The group established a 5 percent prevalence (or higher) as a “reasonable” threshold to recommend screening. It should be noted that the strength of screening recommendations vary as many of these diseases are rare and no existing protocols exist.

American Academy of Pediatrics recently released several guidelines.

• The 2017 guidelines on preventive health care for
  children were approved by the American Academy of Pediatrics (AAP) and the Bright Futures Periodicity Schedule Workgroup and published in the April issue of Pediatrics.
  • Recommendations for screening for dyslipidemia have been updated to occur once between 9 and 11 years of age and once between 17 and 21 years of age to be consistent with guidelines of the National Heart, Lung, and Blood Institute.
• • Universal screening for HIV has been updated to occur once between 15 and 18 years of age to be consistent with recommendations of the U.S. Preventive Service Task Force.

• The AAP’s Committee on Nutrition, Section on Endocrinology and Section on Obesity published a clinical report on screening for components of metabolic syndrome (MetS) in children in the August issue of Pediatrics. While MetS is defined in adults as the presence of any three of five cardiovascular disease risks: hyperglycemia, hypertriglyceridemia, central adiposity, elevated blood pressure, and low high-density lipoprotein cholesterol, diagnosis remains controversial in pediatric populations. The AAP urges pediatricians to follow current recommendations to screen for and treat obesity, glucose abnormalities, hypertension, and dyslipidemia to address the major MetS-associated cardiometabolic risks in pediatric populations. This includes

• Lipid screening (nonfasting or fasting) in all children between the ages of 9 and 11 years.

• Fasting glucose testing every two years for children 10 years or older (or pubertal) with a body mass index at the 85th percentile or greater and two additional risk factors.