eBulletin Newsletter

NCCN Flash Updates: NCCN Guidelines Updated for Survivorship

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Survivorship. These NCCN Guidelines® are currently available as Version 1.2024.

Link directly to the Updates section of the NCCN Guidelines: Survivorship

Terminologies in all NCCN Guidelines are being actively modified to advance the goals of equity, inclusion, and representation.

General Survivorship Principles

SURV-4

  • 1st bullet revised: "...longer be involved in the survivor's care and may also occur at younger ages than in the general population."
  • 2nd bullet revised: "... (eg, smoking, environmental exposures, health behaviors, human papillomavirus [HPV]), and mutagenic effects of cancer treatment. Health behaviors should be modified as possible (eg, smoking cessation, weight management) to decrease the risk of subsequent malignancies."
  • 3rd bullet revised: Treatment-related subsequent primary cancers vary with the type and intensity of anticancer treatment..."
  • Bullet removed: Healthy lifestyle and behavioral counseling are important to reduce risk factors that may contribute to subsequent cancers (HL-1).

SURV-4A 1 of 5

  • General:
    • New bullet added at the top: These treatment related screening and early detection recommendations are distinct from and should not replace surveillance for recurrence of the index cancer.
    • The "Treatment-Related Subsequent Primary Cancers by Treatment Exposure" tables (formerly SURV-C) were moved up in the algorithm to follow the section on "Screening for Subsequent New Primary Cancers" (SURV-4). Previously the table followed the "Survivorship Resources For Health Care Professionals And Survivors" pages (SURV-B).
      • New statement added to the table title: This table does not cover all populations, and additional cancer screenings may be warranted depending on clinical circumstances.
      • Radiation Therapy, Including Total Body Irradiation (TBI); Head and neck; Mucosal head and neck cancer
        • Screening and Early Detection Recommendations revised: Annual head and neck exam (including direct or indirect laryngoscopy as clinically indicated), and/or otolaryngology referral.
        • Comments: Bullet added, For smoking-related cancer, evaluate indications for lung cancer screening

SURV-4A 3 of 5

  • Radiation Therapy, Including Total Body Irradiation (TBI); Abdomen/Flank/Pelvic; Colorectal cancer; Comments revised:
    • New bullet added: Repeat colorectal cancer screening every 3 years after multi-target stool DNA test or every 5 years after colonoscopy. Consultation with primary care, gastroenterologist, or oncologist should be considered as clinically indicated.
    • New bullet added: Also see NCCN Guidelines for Colorectal Cancer Screening
    • Bullet removed: Repeat colorectal cancer screening based on findings, in consultation with primary care, gastroenterologist, or oncologist.
  • Footnote c is new: Children’s Oncology Group Long-Term Follow Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers – Version 6.0 (October 2023).

SURV-4A 4 of 5

  • Transplant Conditioning Therapy (RT or chemotherapy); Hematopoietic Cell Transplantation; Screening and Early Detection Recommendations: New arrow sub-bullet added, Consider increased frequency/intensity of cancer screenings (eg, cervical) for immunocompromised individuals.
  • Systemic Therapy; PARP Inhibitors Lutetium-octreotide; Screening and Early Detection Recommendations: New bullet added, Consider referral to hematology for work up for persistent cytopenias or leukopenias.
  • Footnote d is new: Specific populations such as hematopoietic cell transplantation (HCT) survivors may have additional considerations for
    cancer screening.

SURV-6

  • Care providers are also encouraged to assess the following at regular intervals; Point #9 revised: Fertility concerns for adults of childbearing potential reproductive age

SURV-A 2 of 2

  • Survivorship Assessment; Healthy Lifestyle; Provider Key section revised: If NO to question 23 or 24, or YES to question 25, OR if question 23a is less than 3 times per week, OR if body mass index (BMI) is not in the healthy range between 18.5–24.9 kg/m2, refer to HL-1

SURV-B 1 of 5 through SURV-B 5 of 5 Survivorship Resources For Health Care Professionals And Survivors

PREVENTIVE HEALTH

Healthy Lifestyles

HL-1

  • 3rd bullet;
    • 4th arrow sub-bullet revised: Maintain a healthy diet high in vegetables, fruits, beans/legumes, and whole grains.
    • 7th arrow sub-bullet; New diamond sub-bullet added: Avoid secondary exposure to cigarette smoke.
    • 9th arrow and diamond sub-bullets revised
      • Strive for at least 7–9 hours of sufficient sleep on a regular basis (SSD-1).Recommended total sleep duration:
        • Younger adults require more sleep.Adults: 7–9 hours
        • Teenagers may require 9 or more hours of sleep.Adolescents: 8–10 hours
        • Older adults: 7–8 hours

 

HL-1A

  • Footnote a revised: Highly (sometimes referred to as "ultra") processed foods are made mostly or entirely from substances derived from foods and additives, with little or no intact food (eg, soft drinks, sweet or savory packaged snacks, reconstituted meat products [eg, sausage, chicken nuggets], prepared frozen dishes). Monteiro CA, et al. Public Health Nutr 2018;21:5-17. Highly (sometimes referred to as "ultra") processed foods are industrial formulations typically with 5 or more and usually many ingredients (eg, soft drinks, sweet or savory packaged snacks, reconstituted meat products [eg, sausage, chicken nuggets], prepared frozen dishes). Besides salt, sugar, oils, and fats, ingredients of ultra-processed foods include food substances not commonly used in culinary preparations, such as hydrolyzed protein, modified starches, and hydrogenated or interesterified oils, and additives whose purpose is to imitate sensorial qualities of unprocessed or minimally processed foods and their culinary preparations or to disguise undesirable qualities of the final product. (Martínez Steele E, et al. BMJ Open 2016;6:e009892).
  • Reference is new: Paruthi S, et al. J Clin Sleep Med 2016;12:785-786.

Physical Activity

SPA-1

  • 5th bullet revised: Avoid prolonged sedentary behavior (eg, sitting for long periods, prolonged screen-based activities)
  • Footnote a: 2nd and 3rd bullet references updated

SPA-2

  • Physical Activity Assessment; Assessment of comorbidities and treatment effects as appropriate
    • 12th bullet revised: Thrombocytopenia/pancytopenia and/or coagulopathies
    • New bullet added: Presence of limb prosthesis

SPA-3

  • Risk Assessment For Physical Activity-Induced Adverse Events; 1st column; 2nd pathway; New bullet added: Presence of limb prosthesis.

SPA-A

  • 6th bullet revised: For survivors with peripheral neuropathy, resistance weight machines and/or training with resistance bands are recommended over free weights. If there is a concern that peripheral neuropathy may increase the risk of dropping free weights, survivors could consider utilizing weight machines and/or training with resistance bands.

SPA-B

  • Examples of Physical Activity: The activities for all three levels of exercise were alphabetized.

SPA-C

  • Considerations for Specific Populations;
    • Survivors with established lymphedema; New arrow sub-bullet added: Survivors at risk for upper extremity lymphedema should be encouraged to perform arm/shoulder exercises (SLYMPH-1).
    • New bulleted section added for Presence of limb prosthesis or limb amputation
    • Survivors with peripheral neuropathy
      • 2nd arrow sub-bullet revised: "Consider alternative aerobic exercise (stationary biking, water aerobics, yoga)..."
      • 1st diamond sub-bullet revised: "Consider use of water shoes/protective footwear with aerobic exercise..."
      • New diamond sub-bullet added: Assistance with walking should be provided if alternative aerobic activities are not possible
    • Survivors with bone loss or bone metastases; New bullet added: Consider checking vitamin D levels and use of supplemental vitamin D
      if appropriate

Nutrition and Weight Management

SNWM-1

  • 1st bullet revised: "...as well as red and processed meats, alcohol, dietary supplements, and processed foods..."
  • 3rd bullet; All survivors should be encouraged to; Arrow sub-bullets revised:
    • ....fruit, beans/legumes, and whole grains
    • Eat Limit consumption of processed meats such as ham, hot dogs, deli cuts, bacon, and sausage sparingly if at all.
    • Limit consumption of “fast foods” and other processed foods that are high in fat...
    • Track Monitor calorie intake.
  • 4th bullet; 1st arrow sub-bullet revised: Consider referral to a registered dietitian or nutritionist
  • 5th Bullet; Arrow sub-bullets revised
    • Fat: plant sources such as olive or canola oil, avocados, seeds and nuts, and fatty cold water fish
    • Protein: poultry, fish, legumes, low-fat dairy foods, eggs, and nuts
  • Footnote "f" is new: Examples of "cold water fish" include mackerel, salmon, herring, and others

SNWM-2

  • 1st bullet revised: All survivors should be encouraged to achieve and maintain a normal BMI between 18.5 and 24.9 kg/m2 and strive..."
  • Arrow sub-bullets revised
    • Intentional weight gain should be a priority for survivors who have underweight. (SNWM-4)
    • Intentional weight loss should be a priority for survivors who have overweight/obesity.
      • Diamond sub-bullet revised: Weight gain after cancer diagnosis and treatment is common and can may exacerbate risk for functional decline, comorbidity, and possibly cancer recurrence or death, and can may reduce quality of life.
    • Weight maintenance should be a priority for survivors who have a normal weight BMI between 18.5 and 24.9 kg/m2.
  • 4th bullet revised: Providers should discuss strategies and goal setting for weight management...
    • Diamond sub-bullet revised: Track Monitor weight, diet, calories...
  • Footnote h revised: Many hospitals employ use CSOs and those in private practice...

SNWM-3

SNWM-4

  • Weight gain
    • 2nd bullet revised: Discuss increasing frequency of feeding and portion size
    • 5th bullet revised": "Consider referral to registered dietitian for individualized counseling
    • New bullets added
      • Optimize nutritional density and caloric quality of food
      • Consider appetite stimulants
      • Monitor weight regularly
  • Weight maintenance
    • 1st bullet revised: Reinforce maintenance of normal healthy body weight throughout lifetime
    • Bullet added: Promote regular physical activity (SPA-1)

SNWM-4

  • Weight loss
    • New bullet added: Promote regular physical activity (SPA-1)
    • 9th bullet revised: Refer to registered dietitian or weight management programs for individualized help as needed
    • Last bullet revised: Consider evaluation for bariatric surgery or pharmacologic therapy as appropriate (if BMI ≥30 kg/m2)

General Principles of Supplement Use

SSUP-1

  • 1st bullet revised: Supplement use is not recommended for most survivors, except in instances of documented deficiencies, inadequate diet, previous gastrointestinal surgery that may cause deficiencies (eg, Roux-en-Y gastric bypass), or comorbid indications...
  • 5th bullet revised: Refer survivors using supplements not prescribed by a medical provider to a registered nutritionist/dietitian...

Immunizations and Infections

SIMIN-1

  • General: Link to the NCCN COVID-19 Resources (https://www.nccn.org/covid-19) was removed from the algorithm.
  • Footnote b revised: Also see: Freedman MS, Ault K, Bernstein H. Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older - United States, 2021. MMWR Morb Mortal Wkly Rep 2021;70:193-196 Murthy N, Wodi AP, McNally VV, et al. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2024. MMWR Morb Mortal Wkly Rep 2024;73:11-15. (Also for SIMIN-C)

SIMIN-2

SIMIN-3

  • Recommended for all cancer survivors; Treatment: Tetanus, diphtheria, pertussis (Tdap) vaccine vaccination

SIMIN-3A

  • Footnotes revised
    • Footnote q: Recommendations regarding COVID-19 vaccines are continually changing (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html). For guidance about COVID-19 vaccine usage in patients with cancer the management of concurrent COVID-19 and cancer, please see the NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections. please see NCCN: Cancer and COVID-19 Vaccination https://www.nccn.org/covid-19.
    • Footnote s: Recommended in high-risk patients or those with functional or anatomic asplenia. Committee on Infectious Diseases. Pediatrics 2016;138:e20161890 Mbaeyi SA, Bozio CH, Duffy J, et al. Meningococcal Vaccination: Recommendations of the Advisory Committee on Immunization Practices, United States, 2020. MMWR Recomm Rep 2020;69:1-41.

SIMIN-B 1 of 6 General Principles Of Vaccines In Cancer Survivors

  • Meningococcal conjugate vaccine, quadrivalent (MCV4); Population revised: Splenectomized/functional asplenia survivors Survivors with surgical or functional asplenia

SIMIN-B 2 of 6

  • Vaccination in Survivors Who Had Cellular Therapy (ie, HCT, CAR T-cell therapy)

SIMIN-B 3 of 6

  • Vaccination in All Other Survivors
    • Pneumococcal vaccine; Population; New bullet added: Survivors with surgical or functional asplenia
    • Vaccine: Haemophilus influenzae type b (Hib) vaccine recommendations added to the table

SIMIN-B 4 of 6

  • Vaccination in All Other Survivors
    • Meningococcal conjugate vaccine quadrivalent (MCV4); Population revised: Splenectomized/functional asplenia survivors changed to Survivors with surgical or functional asplenia

SIMIN-B 5 of 6

  • References updated as follows:
    • Refrence 3 Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71;109-117 Kobayashi M, Pilishvili T, Farrar JL, et al. Pneumococcal Vaccine for Adults Aged ≥19 Years: Recommendations of the Advisory Committee on Immunization Practices, United States, 2023. MMWR Recomm Rep 2023;72:1-39.
    • Reference 4Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for use of herpes zoster vaccines. MMWR Morb Mortal Wkly Rep 2018;67:103-108. https://www.cdc.gov/mmwr/volumes/67/wr/mm6703a5.htm Anderson TC, Masters NB, Guo A, et al. Use of Recombinant Zoster Vaccine in Immunocompromised Adults Aged ≥19 Years: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:80-84.
    • Reference 5Freedman MS, Ault K, Bernstein H. Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older - United States, 2021. MMWR Morb Mortal Wkly Rep 2021;70:193-196. Murthy N, Wodi AP, McNally VV, et al. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2024. MMWR Morb Mortal Wkly Rep 2024;11;73:11-15. (Also for SIMIN-C)
    • Refrence 6 is new: Briere EC, Rubin L, Moro PL, et al. Prevention and Control of Haemophilus influenzae Type b Disease:
      Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2014;(RR01):1-14.

SIMIN-B 6 of 6

  • Footnote g revised: Administration of the flu vaccine to survivors with egg allergy symptoms (other than hives) should be done at a center that can manage severe allergic reactions if an egg-based vaccine is used. Grohskopf LA, Alyanak E, Ferdinands JM, et al. Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices - United States, 2021-2022 influenza season. MMWR Recomm Rep 2021;70:1-28 Grohskopf LA, Blanton LH, Ferdinands JM, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2023–24 Influenza Season. MMWR Recomm Rep 2023;72:1-25. (Also for SIMIN-C)

SIMIN-C

  • Principles of Influenza Vaccine(s)
    • 2nd bullet link updated: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8407757 https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html
    • Preferred Vaccines list revised as follows
      • Inactivated influenza vaccine (IIV)
        • Trivalent (IIV3), standard dose
        • Trivalent (IIV3), high dose
        • Quadrivalent (IIV4), standard dose
        • Quadrivalent (IIV4), high-dose (HD-IIV4; preferred in option for survivors ≥65 y)
        • Quadrivalent adjuvanted inactivated influenza vaccine (aIIV4; preferred option for survivors ≥65 y)
      • Recombinant influenza vaccine (RIV)a
        • Trivalent (RIV3)
        • Quadrivalent (RIV4; preferred option for survivors ≥65 y)

LATE EFFECTS/LONG-TERM PSYCHOSOCIAL AND PHYSICAL PROBLEMS

Cardiovascular Disease Risk Assessment

SCVD-1

  • 4th bullet revised: Cancer treatments (immunotherapy, cytotoxic, HCT, and targeted systemic therapies, RT) can result...
  • 7th bullet revised: Tools exist to help quantify atherosclerotic CVD (ASCVD) risk (eg, ASCVD risk score) and thus determine appropriate risk reduction strategies.
  • Bullet removed: Consider referral to cardio-oncology or a cardiology specialist for high-risk survivors.

Anthracycline-Induced Cardiac Toxicity

SCARDIO-2

  • Initial Clinical Assessment For Patients Who Have Received Previous Anthracycline Therapy; 3rd bullet; 2nd arrow sub-bullet revised: Other systemic therapy (eg, anti-HER2 treatment) and/or chest RT.
  • Footnote d revised: "...shortness of breath when sleeping laying flat (ie, orthopnea), waking up at night due to shortness of breath...

SCARDIO-3

  • Treatment
    • Stage A; 3rd bullet revised: Consider referral to cardiologist for management
    • Stage B, Stage C, Stage D pathways; Bullet revised: Referral to cardiologist cardiovascular specialist (ie, cardiologist, cardio-oncologist) for management
  • Footnote n revised: Consider referral to a cardiologist, especially cardio-oncologist, survivorship specialist, or PCP for serial surveillance based on cardiotoxicity risk of cancer treatment regimen or if additional anthracycline therapy or other cardiotoxic treatment is needed.

Anxiety, Depression, Trauma, and Distress

SANXDE-7

  • Social/External Factors; New arrow sub-bullet added: Discrimination or marginalization because of race, ethnicity, sexual orientation, sexual identity, or disability status

Cognitive Function

SCF-1

  • General Principles; 3rd bullet revised: "...cancer-associated cognitive dysfunction has been identified, and screening tools. Existing diagnostic tools do not strongly correlate with patient reports of cognitive dysfunction.

SCF-3

  • General Strategies for Management of Cancer-Associated Cognitive Dysfunction: New bullet added, Involve social support system to help with completion of tasks and activities

SCF-4

  • Second-line Interventions; 1st bullet revised: "...and care for survivors who continue to have memory cognitive problems after rehabilitation

Fatigue

SFAT-1

  • Considerations For Fatigue In Cancer Survivors
    • 1st bullet; 1st arrow sub-bullet revised: "Receipt of chemotherapy, radiation, endocrine, immunotherapy, targeted, and/or cellular therapies..."
    • New arrow sub-bullet added: Assessment and communication regarding fatigue and anticipated recovery after treatment should be done periodically.

Lymphedema

SLYMPH-1

SLYMPH-3

  • Screening; 1st bullet; 3rd arrow sub-bullet revised: Swelling, tightness, or uncomfortable sensation that interferes with daily activities
  • Workup If Lymphedema Is Suspected; 1st bullet revised: Rule out recurrence of cancer, infection, or deep vein thrombosis (DVT) of an extremity

SLYMPH-A

  • Survivor Lymphedema Education; 1st bullet; 3rd arrow sub-bullet revised: "...maintenance of skin integrity on the affected side, manual drainage, and range of motion exercise."
  • Footnote b revised: For a complete list of lymphedema risk reduction practices, see the Position Statement from the National Lymphedema Network:
    https://issuu.com/lymphnet/docs/risk_reductionhttps://lymphnet.org/position-papers.
  • Footnote c is new: Limb elevation can be used as an option for early-stage lymphedema for short-term improvement, but data are limited.

Pain

SPAIN-1

  • 6th bullet; New arrow sub-bullet added: Hypnosis, meditation, acupuncture, cognitive restructuring, and behavioral activation can be considered to control pain and maximize function.
  • The arrow sub-bullet "Physical modalities (heat, cold, massage, acupuncture, physical therapy, or occupational therapy) are useful and should be considered for some pain syndromes." was previously the 7th bullet.
  • Footnote is new: Thompson T, Terhune DB, Oram C, et al. The effectiveness of hypnosis for pain relief: A systematic review and meta-analysis of 85 controlled experimental trials. Neurosci Biobehav Rev 2019;99:298-310.

SPAIN-2

SPAIN-9

  • GI/urinary/pelvic pain; Treatment; For GI pain (abdominal pain/cramping): Bowel regimen added as an option

Hormone-Related Symptoms

SHRS-1

  • Principles of Menopause Symptom Management In Female Survivors; Treatment Options for Vasomotor Symptoms; Hormonal therapies; New arrow sub-bullet added: Survivors often use herbal supplements for vasomotor symptom management. However, some supplements may interfere with hormonal cancer treatments, and routine use of supplements is not recommended (SSUP-1). Providers should encourage survivors to discuss such therapies prior to use. (Also for SHRS-2A)

SHRS-A 1 of 2

  • Non-Hormonal Pharmacologic Treatments And Dosing For Vasomotor Symptoms; New drug class entry and recommendations added for Selective neurokinin-3 (NK3) receptor antagonist

SHRS-B

  • Principles Of Menopausal Hormone Therapy (MHT) Use In Female Survivors; 2nd bullet, New sub-bullets added
    • The tissue-selective estrogen complex (TSEC) conjugated estrogens/bazedoxifene is FDA-approved for treating menopausal symptoms in healthy post-menopausal survivors.
      • These drugs are contraindicated in survivors of hormonally dependent cancers.

Sexual Health

SSH-3

  • Male with concerns/issues regarding sexual health; Problems with ejaculation (premature, absent, delayed, or climacturia); Treatment Options; 4th bullet revised: "For climacturia: Empty bladder prior to sex, pelvic physical therapy, or trial of imipramine use of condoms to catch urine"

SSH-3A

  • Footnote m revised: "...prostate cancer under therapy with androgen deprivation). Exogenous testosterone therapy should not be prescribed to those who are currently trying to conceive. The long-term impact of exogenous testosterone on spermatogenesis should be discussed with patients who are interested in future fertility."

Sleep Disorders

SSD-1

  • 3rd column; H&P; Arrow sub-bullet; Comorbidities; Revised: Iron and ferritin levels and when indicated transferrin saturation %
  • 4th column; Bottom pathway; Sleep disturbance and/or excessive sleepiness:
    • New bullet added: Sleep disordered breathing (includes obstructive sleep apnea [most common] and central sleep apnea)
    • Bullet removed: Obstructive sleep apnea

SSD-1A

  • Footnote c revised: Consider Medication review: Re-evaluate the need for persistent use of sleep aids, pain medications, antiemetics, stimulants..."
  • Footnote e revised: "Note that sleep disordered breathing (eg, obstructive sleep apnea), RLS, circadian rhythm sleep wake disorders, and parasomnias..."

SSD-2

  • 3rd column; Top pathway; Evaluate for and address comorbid causes; New bullet added: Other sleep disorders

SSD-3

  • Associated with observed apneas, snoring pathway; Diagnosis revised for Sleep Study: Obstructive sleep apnea changed to Sleep disordered breathing
  • Associated with uncomfortable sensation; Treatment; Management options revised under "Initial preferred therapy"
    • Gabapentin enacarbil added
    • Enacarbil removed
  • Footnote o revised: The following tools may be used to help identify individuals at high risk for obstructive sleep apneas...
  • Footnote r revised: Sleep studies can be done performed as an in-laboratory polysomnography or as home sleep study. However, survivors with known certain medical disorders (ie, cardiac, disease or respiratory, neurologic disease), who have used or currently on opiates for cancer-related pain, may not be good candidates for some home sleep tests studies.
  • Footnote t revised: The most common medical treatment for obstructive sleep apnea sleep disordered breathing is continuous positive airway pressure (CPAP).

SSD-A

  • Other Sleep Interventions revised
    • 1st bullet: If survivor is not able to fall asleep within 45 minutes what feels like 20 minutes (survivor should not check the clock) or...
    • Arrow sub-bullets:
      • Get up, go to a different location, but stay in a darkened room and do non-stimulating activity like watching a relaxing TV show or reading..."
      • "...reduce worrying (ie, write a "to do" list or set aside "worry time" [eg, 10–15 mins] earlier in the day, not close to bedtime)"

SSD-B

  • Footnote b is new: There are paid and/or free guided, semi-guided, and unguided CBT-I digital resources available. See Survivorship Resources for Health Care Professionals and Survivors (SURV-B).

SSD-C

  • Footnote d revised: "...and nutritional/herbal supplements (eg, melatonin). They do not have an FDA-approved indication..."

SSD-D

  • Section title revised: Iron Deficiency And Restless Legs Syndrome
  • New arrow sub-bullet added: Consider referral to specialist for refractory symptoms (See NCCN Guidelines for Palliative Care)
  • New bullet added: Consider modification of lifestyle factors and medications that can exacerbate RLS symptoms
  • Footnote c is new: Alcohol, nicotine, caffeine, centrally active antihistamines, SSRI, SNRI, and dopaminergic medications are associated with worsening of RLS symptoms.

 

 

 

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