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NCCN Flash Updates: NCCN Guidelines Updated for Gastric Cancer

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®), the NCCN Drugs & Biologics Compendium (NCCN Compendium^®), and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™) for Gastric Cancer. These NCCN Guidelines^® are currently available as Version 2.2023.

Link directly to the Updates section of the NCCN Guidelines: Gastric Cancer

Updates in Version 2.2023 of the NCCN Guidelines for Gastric Cancer from Version 1.2023 include:

General

• Revised language as follows:
  • Chest/abdominal abdomen CT
  • Pelvic Pelvis CT

GAST-1

• Workup
  • 10th bullet revised: "HER2 and PD-L1 testing if metastatic adenocarcinoma disease is documented/suspected

GAST-2

• Locoregional disease (cM0); Medically fit potentially resectable pathway; Primary Treatment for cT2 or higher, Any N: "Consider neoadjuvant or perioperative immune checkpoint inhibitor(s) (ICI) if tumor is MSI-H/dMMR" added as a treatment option.
• Footnote r is new: In patients with a MSI-H/dMMR tumor, perioperative immunotherapy or surgery alone should be considered in consultation with a multidisciplinary team.
• Footnotes s is new: The role of surgery after biopsy proven and radiologic/metabolic complete response on neoadjuvant immunotherapy is unclear. The role for surgery in the setting of favorable neoadjuvant response should be carefully discussed.

GAST-3

• Primary Treatment Options for Patients Who Are Medically Fit: New pathway added for "Neoadjuvant or perioperative ICI if tumor is MSI-H/dMMR".
  • The following footnotes are new:
    • Footnote r: In patients with a MSI-H/dMMR tumor, perioperative immunotherapy or surgery alone should be considered in consultation with a multidisciplinary team.
    • Footnote s: The role of surgery after biopsy proven and radiologic/metabolic complete response on neoadjuvant immunotherapy is unclear. The role for surgery in the setting of favorable neoadjuvant response should be carefully discussed.
    • Footnote t: Assessment ≥5 to 8 weeks after completion of preoperative therapy.
    • Footnote u: Pelvis CT if clinically indicated.
    • Footnote v: See Post-Treatment Surveillance–Principles of Endoscopic Staging and Therapy (GAST-A 2 of 3).
    • Footnote w: If surgery is not being considered for management, upper GI endoscopy and biopsy should be done.
    • Footnote x: Feeding jejunostomy for postoperative nutritional support, generally preferred.

GAST-4

• Column header revised: Surgical Outcomes/Clinical Pathologic Findings (Patients Have Not Received Preoperative Chemoradiation Or Chemotherapy Systemic Therapy). (Also for GAST-5)

GAST-5

• Postoperative Management for R0 resection: Recommendation revised: "Chemotherapy Systemic therapy if received perioperatively (category 1)."

Principles of Pathologic Review and Biomarker Testing

GAST-B 5 of 6

• Next-Generation Sequencing (NGS); 1st bullet revised: "...Trastuzumab is based on testing for HER2 overexpression. Pembrolizumab/nivolumab are Use of select PD-1/PD-L1 inhibitors immune checkpoint inhibitors is based on testing for MSI by PCR or NGS/MMR by IHC, PD-L1 immunohistochemical expression, or high tumor mutational burden (TMB) by NGS. The FDA granted..."

Principles of Systemic Therapy

GAST-F 1 of 19

• 8th Bullet revised: "Perioperative systemic therapy is a category 1 recommendation..."
• Last bullet revised: "In the adjuvant setting, upon completion of chemotherapy systemic therapy or chemoradiation..."

GAST-F 3 of 19

• New table added for Neoadjuvant or Perioperative Immunotherapy.
  • The new table includes the following regimens for MSI-H/dMMR tumors under "Useful in Certain Circumstances":
    • Nivolumab and ipilimumab followed by nivolumab
    • Pembrolizumab
    • Tremelimumab and durvalumab for neoadjuvant therapy only

Principles of Systemic Therapy for Unresectable Locally Advanced, Recurrent, or Metastatic Disease

GAST-F 4 of 19

• First-Line Therapy
  • Preferred Regimens: The following new section and regimens were added:
    • MSI-H/dMMR tumors (independent of PD-L1 status)
      • Pembrolizumab
      • Dostarlimab-gxly
      • Nivolumab and ipilimumab
      • Fluoropyrimidine (fluorouracil or capecitabine), oxaliplatin, and nivolumab
      • Fluoropyrimidine (fluorouracil or capecitabine), oxaliplatin, and pembrolizumab

GAST-F 5 of 19

• Second-Line or Subsequent Therapy
  • Useful in Certain Circumstances: Nivolumab and ipilimumab for
    MSI-H/dMMR tumors was added as an option.

Principles of Systemic Therapy-Regimens and Dosing Schedules

GAST-F 6 of 19 to GAST-F 15 of 19

• The dosing schedules were extensively revised to reflect the changes in the algorithm.
• In regards to the addition of the nivolumab and ipilimumab combination for first-line therapy (MSI-H/dMMR tumors), the statement and dosing below were also added. A similar statement was also added for second-line or subsequent therapy:
  • The panel acknowledges that the CheckMate-649 trial formed the basis for first-line therapy strategy for metastatic or locally advanced cancer. However, the panel does not recommend the doses and schedule of agents specified in this trial due to concerns regarding toxicity. The panel recommends the following modifications instead:
    • Nivolumab and ipilimumab
      Nivolumab 240 mg IV every 2 weeks
      Ipilimumab 1 mg/kg IV every 6 weeks
      For 16 weeks, followed by
      Nivolumab 240 mg IV every 2 weeks or
      Nivolumab 480 mg IV every 4 weeks
      (maximum of 2 years)

Principles of Systemic Therapy-References

GAST-F 16 of 19 to GAST-F 19 of 19

• The reference pages were updated to reflect the changes in the algorithm.

Principles of Palliative/Best Supportive Care

GAST-J 1 of 3

• Bleeding; 1st bullet: The arrow sub-bullet that stated "External beam radiation therapy (EBRT) has been shown to effectively manage acute and chronic gastrointestinal bleeding in multiple small series" was removed from this section. It was moved under the 2nd bullet for Chronic blood loss from gastric cancer and replaced the arrow sub-bullet that stated "EBRT may be used for chronic blood loss due to gastric cancer."

 

For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Drugs & Biologics Compendium (NCCN Compendium^®), the NCCN Biomarkers Compendium^®, the NCCN Chemotherapy Order Templates (NCCN Templates^®), the NCCN Radiation Therapy Compendium™, and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), please visit NCCN.org.

To view the NCCN Guidelines for Patients^®, please visit NCCN.org/patientguidelines.

Free NCCN Guidelines apps for iPhone, iPad, and Android devices are now available! Visit NCCN.org/apps.

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