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NCCN Flash Updates: NCCN Guidelines Updated for Small Bowel Adenocarcinoma and Anal Carcinoma

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®), the NCCN Drugs & Biologics Compendium (NCCN Compendium^®), the NCCN Radiation Therapy Compendium™, and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™) for Anal Carcinoma. These NCCN Guidelines^® are currently available as Version 1.2024.

Link directly to the Updates section of the NCCN Guidelines: Anal Carcinoma

General

• Metastatic disease regimens have been moved from ANAL-1 through ANAL-4 and added to Systemic Therapy on ANAL-B 2 of 3.
• Imaging language updated throughout.

ANAL-3

• Footnote o modified: Consider the use of immunotherapy (nivolumab, or pembrolizumab, or retifanlimab-dlwr) (category 2B) before proceeding to APR. (Also for ANAL-4)

ANAL-B 1 of 3

• Principles of Systemic Therapy - Localized Cancer
  • Regimen language modified for capecitabine + mitomycin + RT:
    • Capecitabine 825 mg/m² PO BID Monday–Friday, on days of radiation treatment only, throughout the duration of RT (typically 28–30 treatment days), Mitomycin 10 mg/m² days 1 and 29 (capped at 20 mg) with RT
    • Capecitabine 825 mg/m² PO BID days 1–5Monday–Friday, on days of radiation treatment only, throughout the duration of RT (typically 28–30 treatment days) Mitomycin 12 mg/m² IV bolus day 1 (capped at 20 mg) with RT
  • Footnote removed: Monday–Friday, on each day that RT is given, throughout the duration of RT (typically 28–30 treatment days depending on stage). (Also for ANAL-B 2 of 3)

ANAL-B 2 of 3

• Principles of Systemic Therapy - Metastatic Cancer
  • Table headers modified:
    • First-Line Therapy for Metastatic Cancer
    • Second-Line and Subsequent Therapy
  • Second-Line and Subsequent Therapy
    • Preferred Regimens
      • Retifanlimab-dlwr added as a category 2A recommendation
      • Text modified: Preferred Regimens (if no prior immunotherapy received)
    • Regimens and preference added:
      • Other Recommended Regimens (if not previously given)
        • Carboplatin + paclitaxel
        • FOLFCIS
        • mFOLFOX6
        • 5-FU + cisplatin (category 2B)
        • Modified DCF (category 2B)
  • Chemo/RT
    • Regimen language modified for capecitabine + RT: Capecitabine 825 mg/m² PO twice daily on days 1–5 with RTMonday–Friday, on days of radiation treatment only, throughout the duration of RT (typically 28–30 treatment days)
  • Footnote b added with link to: NCCN Guidelines for the Management of Immunotherapy-Related Toxicities

ANAL-B 3 of 3

• Reference added: Rao S, Anandappa G, Capdevila J, et al. A phase II study of retifanlimab (INCMGA00012) in patients with squamous carcinoma of the anal canal who have progressed following platinum-based chemotherapy (POD1UM-202). ESMO Open 2022;7:100529.

ANAL-D 1 of 2

• Counseling Regarding Healthy Lifestyle and Wellness
  • Bullet removed: Consider daily aspirin 325 mg for secondary prevention.

 

 

NCCN has published updates to the NCCN Guidelines, the NCCN Drugs & Biologics Compendium (NCCN Compendium^®), the NCCN Radiation Therapy Compendium™, and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™) for Small Bowel Adenocarcinoma. These NCCN Guidelines are currently available as Version 1.2024.

Link directly to the Updates section of the NCCN Guidelines: Small Bowel Adenocarcinoma

General

• Imaging language updated throughout

SBA-5

• Workup
  • Metastatic adenocarcinoma
    • Testing added: BRAF V600E and consider tumor mutational burden (TMB) testing

SBA-D 1 of 7

• The systemic therapy algorithms have been extensively revised and updated to a table format.
  • Initial Therapy
    • Heading modified: Initial Therapy if previous FOLFOX/CAPEOX in the adjuvant setting within past 12 months or contraindication
      • Regimens added:
        • If BRAF V600E mutation-positive: Dabrafenib + trametinib
        • If TMB-high (>10 mut/Mb): Pembrolizumab (category 2B)
  • Second-line and Subsequent Therapy (if not previously given)
    • Intensive Therapy Recommended
      • Regimens added:
        • If BRAF V600E mutation-positive: Dabrafenib + trametinib
        • If TMB-high (>10 mut/Mb): Pembrolizumab (category 2B)
    • Intensive Therapy NOT Recommended:
      • Regimen added: If TMB-high (>10 mut/Mb): Pembrolizumab (category 2B)

SBA-D 2 of 7

• Footnote removed: Larotrectinib or entrectinib are treatment options for patients with metastatic SBA that is NTRK gene fusion-positive. Selpercatinib is a treatment option for patients with metastatic SBA that is RET gene fusion-positive.

SBA-D 3 of 7

• Adjuvant Therapy Regimens
  • Regimen language modified for capecitabine + RT: Capecitabine 825 mg/m² PO twice daily on days 1–5 with RT Monday–Friday, on days of radiation treatment only, throughout the duration of RT (typically 28–30 treatment days) (Also for SBA-D 5 of 7)
  • Footnote removed: Monday–Friday, on each day that RT is given, throughout the duration of RT (typically 28–30 treatment days depending on stage). (Also for SBA-D 5 of 7)

SBA-D 6 of 7

• Advanced or Metastatic Therapy Regimens
  • Regimen qualifier modified: Pembrolizumab (dMMR/MSI-H only or TMB-high [>10 mut/Mb])
  • Regimen qualifiers modified for the following:
    • Nivolumab (dMMR/MSI-H only)
    • Ipilimumab + nivolumab (dMMR/MSI-H only)
    • Dostarlimab-gxly (dMMR/MSI-H only)
  • Regimen and dosing added for dabrafenib + trametinib (BRAF V600E mutation-positive)

SBA-D 7 of 7

• Reference added: Subbiah V, Kreitman RJ, Wainberg ZA, et al. Dabrafenib plus trametinib in BRAFV600E-mutated rare cancers: the phase 2 ROAR trial. Nat Med 2023;29:1103-1112.

SBA-E

• Principles of Radiation Therapy
  • Duodenum
    • RT Dosing modified: Adjacent small bowel dose should be limited to 50 Gy, V45 Gy should be <195 cc for a bowel bag avoidance, or V15 should be <120 cc for individual small bowel loops, if possible.

 

NCCN has published updates to the NCCN Radiation Therapy Compendium™ for Penile Cancer, version 1.2024.

 

 

 

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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