Society of Interventional Oncology requests updates to NCCN guidelines to more strongly recommend ablation


NCCNThe Society of Interventional Oncology (SIO) is working more closely within cooperative groups and taskforces, as well as amongst the guidelines commentariat, to provide a global voice to interventional radiologists working in cancer care. Within the various groups the society is active amongst, SIO president William (Bill) Rilling (USA) tells Interventional News they have the strongest presence on relevant National Cancer Center Network (NCCN) panels.

SIO is working on developing and submitting evidence-based recommendations to various NCCN panels. Commenting on this growing integration into the formal process of commenting on and reviewing guidelines, Rilling says: “We have been very welcomed into this process, especially by medical oncologists. Everyone can recognise that there is a benefit to the patient to have as broad a view as possible. The vast majority of people involved at the moment [with guideline review] are medical oncologists.”

NCCN kidney cancer guidelines

Earlier this year, updates to the NCCN renal guidelines were submitted by Ronald Arellano (Harvard University, Cambridge, USA), Thomas Atwell (Mayo Clinic, Rochester, USA), and S William Stavropoulos (University of Pennsylvania, Philadelphia, USA) on behalf of SIO. Their letter requests the NCCN kidney cancer guideline panel review six specific changes for inclusion in the management of T1a renal masses.

Speaking to Interventional News, Stavropoulos explains the society’s ambitions for how the guidelines will change: “We hope the NCCN guidelines are updated to accurately reflect the latest research showing the oncologic success and safety of percutaneous ablation for renal cell carcinoma (RCC) relative to surgery and active surveillance.

“It is critical that national guidelines reflect the latest developments in research and clinical practice. Updating the NCCN guidelines will help interventional oncologists at the local and national level. Locally, it could help interventional oncologists during discussions regarding treatment options at individual tumour boards. At the national level, updating the role of ablation in the NCCN guidelines could assist with issues such as funding of clinical trials, procedural reimbursement coverage and industry investment in research and development.”

These specific changes SIO are requesting are:

  • Move text related to thermal ablation to a position in front of surveillance.
  • When addressing relative incidence of local recurrence following thermal ablation compared to surgery, qualification is needed to state that both techniques are very effective and the difference in treatment success is very small or absent (5% or less). For small renal tumours, cancer specific survival is also similar amongst treatment strategies.
  • Benefits of thermal ablation deserve mention in Principles of Surgery.
  • When considering those patients appropriate for thermal ablation, please include “those patients willing to accept a potential very low increased incidence of local recurrence” and “those patients in whom partial nephrectomy is not possible and nephron preservation is imperative”.
  • Recommend the term “in selected patients” be removed below Ablative Techniques and Ablative Techniques be moved above Active Surveillance on page KID-1.
  • Recommend the following change be added to page Kid-B, 2-4, Follow-up after Partial or Radical Nephrectomy: Biopsy or repeat biopsy: New enhancement or enlarging nodularity along the surgical margin following partial nephrectomy or new enhancing mass in the surgical bed following radical nephrectomy.

Atwell outlines his ambitions for the guidelines to Interventional News: “My hope is that we could bring the NCCN guidelines closer to those currently provided by the American Urological Association (AUA) and the American Society of Clinical Oncology (ASCO), both of whom include thermal ablation as a front-line treatment alternative for small renal masses. There are particular attributes of ablation that warrant consideration in the NCCN guidelines, including favourable perioperative outcomes.”

Enthusing about the society’s involvement in these requested guidelines changes, Stavropoulos says: “SIO has been critical in spearheading these type of efforts. For interventional oncology (IO) to take its place as the fourth pillar of cancer care, we need to engage with the major oncology organisations. In this instance, the SIO was instrumental in bringing our RCC working group together and helping us through the specifics of the NCCN submission process. Other areas of SIO advocacy include establishing the first IO Working group within ECOG-ACRIN [a cancer research group formed from a 2012 merger between the Eastern Cooperative Oncology Group and the American College of Radiology Imaging Network], spearheading multiple IO clinical trial concepts in gastrointestinal (GI), genitourinary (GU), and thoracic oncology within the National Cancer Institute (NCI) Cooperative Groups. Establishing a footprint within organised oncology increases the visibility of IO and recognition of what we offer patients among our medical, surgical and radiation oncology colleagues.”

NCCN breast cancer guidelines

SIO also submitted updates to the NCCN breast cancer guidelines this year. Submitted by Amy Deipolyi (Memorial Sloan Kettering Cancer Center, New York, USA), Maureen Kohi (University of California, San Francisco, USA), and Gloria Hwang (Stanford University, Stanford, USA).

Deipolyi explains to Interventional News: “The NCCN publishes guidelines that guide physicians and patients on ‘standards of practice’ for cancer treatment. These guidelines not only drive decision making in tumour boards and in clinic, but are also used by insurance companies to justify witholding reimbursement for procedures and diagnostic exams. The current NCCN guidelines for breast cancer do not mention minimally invasive procedures, despite good evidence that local therapies are effective for palliating pain and liver-directed therapies can confer progression free survival intervals. The NCCN committee for breast cancer does not include a single diagnostic or interventional radiologist. We have petitioned the committee to consider including radiologists, and to consider minimally invasive therapies in the treatment of metastatic breast cancer. Our hope is to improve patient outcomes and to help physicians offer these procedures while minimising the difficulty in obtaining insurance coverage. We appreciate the support and effort of SIO to advocate for interventional oncology physicians and their patients.”

To this end, their letter suggests including a section for locoregional therapies for stage IV metastatic breast cancer and illustrates three clinical examples.

These three clinical examples are: if the patient has painful bone metastases, for oligometastatic disease, and for liver-dominant hepatic metastasis refractory to systemic therapy.

Regarding the first example, the authors write: “Bone metastasis occurs in 65–75% of patients with metastatic breast cancer. Image-guided cryotherapy, heat-based thermal ablation, and cementoplasty have been demonstrated to be effective and fast-acting methods to improve bone pain due to metastasis from a wide range of tumours, including breast cancer.”

Similarly, for oligometastatic disease, Deipolyi, Kohi and Hwang justify their recommendation through this statement: “Local ablative therapies for five or fewer sites of metastasis have been shown to provide longer progression free survival and may prolong overall survival. Hepatic resection and/or thermal ablation of hepatic oligometastatic disease can confer disease free intervals lasting several years and perhaps, more importantly, allow long intervals of disease control without chemotherapy. This is particularly beneficial in patients not tolerating systemic therapy.”

For their final clinical example, they expand: “Liver metastasis commonly occurs in breast cancer patients and is associated with poorer oncologic outcomes. Liver tumours may cause abdominal pain or result in compression of the portal vein or obstruction of bile ducts. In selected patients who are not eligible for resection such as chemoembolization and radioembolization have demonstrated radiologic responses that translate to prolonged patient survival. Combining liver-directed treatments in the management of metastatic breast cancer with liver-only or liver-dominant disease can provide longer disease control while delaying the need to change to another line of systemic therapy. Also, in patients with hormonally responsive breast cancer and new-onset liver metastases, transarterial locoregional therapy can delay the initiation of systemic chemotherapy and benefit the patient’s quality of life.”

NCCN lung cancer guidelines

Additionally, SIO submitted updates to the NCCN non-small cell lung cancer guidelines. The letter was penned by Patrick Eiken (Mayo Clinic, Rochester, USA), Florian Fintelmann (Harvard Medical School, Cambridge, USA) and Robert Suh (David Geffen School of Medicine at UCLA, Los Angeles, USA), and requests updating the role of image-guided thermal ablation in the Clinical Practice Guidelines in Oncology for non-small cell lung cancer.

The letter authors describe image-guided thermal ablation as “inclusive of radiofrequency ablation, microwave ablation and cryoablation” and as “a form of ‘local therapy’ or ‘local ablative therapy’ and, generally, may be considered as a potential alternative to other local therapies, particularly for lung lesions <3cm”.

They argue for the inclusion of a section on the principles of image-guided thermal ablation in the NCCN non-small cell lung cancer guidelines, as well as the addition of a section titled “Image-guided thermal ablation” in the discussion of treatment approaches in the guidelines. Currently, the guidelines include a similar section on the principles of radiation therapy; Eiken, Fintelmann and Suh say that as image-guided thermal ablation is “increasingly being studies and used clinically in the treatment of lung cancer”, including a summary of what it is and of its appropriate applications “would be useful to  include”.

The third specific change called for by these interventionists is to give greater attention to ablation for medically inoperable stage IA cancer under the “initial treatment” options. Currently, when deemed medically inoperable, the guidelines suggest stereotactic ablative radiotherapy (SABR), with two footnotes, m and n. SIO is calling for NCCN to delete footnote “n” (which reads “Interventional radiology ablation is an option for selected patients”) and to include image-guided thermal ablation in the algorithm proper, alongside SABR. They state their rationale for this: “A growing volume of literature shows the efficacy of image-guided thermal ablation for local control of primary and secondary malignancies of the lung. While the evidence for surgery or SABR may be more robust, use of image-guided thermal ablation may expand the pool of patients for whom local tumour control is possible. Image-guided thermal ablation may be of particular value in patients with limited pulmonary reserve or for those who have reached the limits of tissue toxicity from radiation therapy.”

  • A further five changes are specified in the letter:
  • To swap the positions of “Radiation” and “Ablation”, so that ablation is a higher consideration for patients with multiple lung cancers where definitive local therapy is possible. To change “Ablation” to “Image-guided thermal ablation”. The authors justify this recommendation: “In the setting of multiple lung cancers, preservation of lung parenchyma and feasibility of repeat treatments are paramount considerations, as repeat treatments are expectedly necessary over time. Both lung parenchymal sparing and repeatability are strengths of image-guided thermal ablation relative to radiation.”
  • Add “Image-guided thermal ablation” as a third option, after surgical resection or SABR, for patients where definitive therapy for local disease is feasible. The rationale for this is described thus: “A growing volume of literature shows the efficacy of image-guided thermal ablation for local control of primary and secondary malignancies of the lung. While the evidence for surgery or SABR may be more robust, use of image-guided thermal ablation may expand the pool of patients for whom local control of the tumour is possible. Image-guided thermal ablation may be of particular value in patients with limited pulmonary reserve or those who have reached the limits of tissue toxicity from radiation therapy.”
  • To add image-guided thermal ablation into the footnote that defines “Definitive local therapy for metastatic site”. This currently reads: “Typically, RT (including SABR) or surgical resection”.
  • To add “Image-guided thermal ablation” to the algorithm proper under “External-beam RT or SABR” and delete the footnote (where it currently resides) when recommending therapy for recurrence and metastasis.
  • On NSCL-19, 20, 22 and 23, change each instance of “Consider definitive local therapy (e.g., SABR or surgery) for limited lesions to “Consider definitive local therapy (e.g., Image-guided thermal ablation, SABR or surgery) for limited lesions.


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