National Comprehensive Cancer Network. (2015). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Survivorship [v.2.2015]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf
PHASE OF CARE: Late effects and survivorship
All recommendations were based on lower level evidence and consensus.
Physical activity and memory aids were recommended for cognitive impairment. SSRIs and SNRIs were recommended for depression as first-line treatment, and benzodiazepines were recommended as first-line treatment for anxiety. Physical activity, cognitive behavioral therapy, psychoeducation, and the consideration of psychostimulants were recommended for fatigue.
This guideline gave numerous recommendations and suggestions for various aspects of patient needs. Most recommendations were consensus-based.
National Comprehensive Cancer Network. (2012). NCCN Clinical Practice Guidelines in Oncology: Palliative Care [v.2.2012]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf
The objective of the guidelines is to provide palliative care practice guidelines for patients with cancer, facilitating the appropriate integration of palliative care into oncology practice.
These are consensus-based guidelines.
Included in the guidelines are multiple phases of care with palliative care applications.
The NCCN made recommendations on the following symptoms.
Anorexia
Nutritional support, including enteral and parenteral feeding, should be considered. Appetite stimulants such as megestrol acetate and corticosteroids can be used when appetite is an important aspect of quality of life.
Chemotherapy-Induced Nausea and Vomiting (CINV)
Recommendations include prochlorperazine, haloperidol, metoclopramide, or benzodiazepines. Adding 5-HT3 receptor agonists, anticholinergics, antihistamines, corticosteroids, antipsychotics, and cannabinoids also can be considered. Palliative sedation can be considered as a last resort.
Constipation
Increase fluid intake, dietary fiber, and physical activity. Opioid-induced constipation should be anticipated and treated prophylactically with laxatives.
Dyspnea
Pharmacologic interventions include opioids or benzodiazapines. Scopolamine, atropine hyoscyamine, and glycopyrrolate are options to reduce excessive secretions.
Pain
Do not reduce opioid dose for symptoms such as decreased blood pressure or respiratory rate. Palliative sedation can be considered for refractory pain.
Sleep/Wake Disturbances
For refractory insomnia with no underlying physiologic cause, pharmacologic management includes diazepam, zolpidem, and sedating antidepressants. Cognitive behavioral therapy may be effective. If present, restless leg syndrome can be treated with ropinirole.
Recommendations provide expert opinion/consensus-level suggestions for management of various symptoms. Many recommendations, such as those for CINV, do not agree with current evidence in these areas.
National Comprehensive Cancer Network. (2015). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Palliative care [v.1.2016]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf
RESOURCE TYPE: Consensus-based guideline
PROCESS OF DEVELOPMENT: Guidelines were developed by a panel
These guidelines did not provide a specific search strategy or information about literature search results.
These recommendations were made mainly by consensus, and the guidelines provided no information about literature search results and appeared to use only one database for searching. All suggestions were based on low-level evidence and uniform consensus.
These guidelines provided numerous suggestions for the management of various symptoms, but they were not truly evidence-based. In those aspects for which there was no research evidence, the guidelines provided expert opinion suggestions for management.
National Comprehensive Cancer Network. (2011). NCCN Clinical Practice Guidelines in Oncology: Cancer-Related Fatigue. Version 1.2011.
To ensure that all cancer patients with fatigue were identified and treated promptly and effectively. These guidelines included recommended standards of care for assessment and management of fatigue in children, adolescents, and adults with cancer.
The guidelines were evidence- and consensus-based. The guidelines were multidisciplinary, and all recommendations were category 2A unless otherwise stated.
The guidelines provided several algorithms for assessment and management based on age group, level of self-reported fatigue, and phase of treatment.
Screening
Focused Evaluation of Fatigue
Management and Interventions
Within activity enhancement information, the guideline cites several synthesized reviews regarding the use of exercise and concludes that
Because fatigue is a subjective experience, it was recommended that assessment should use patient self-reports and other sources of data.
Several barriers were identified related to effective treatment for fatigue. Due to barriers, it was stated that screening for fatigue needs to be emphasized. Rescreening was emphasized because fatigue may exist beyond the period of active treatment.
Factors identified as potential causative agents that should be specifically assessed were outlined. These factors were pain, emotional distress, sleep disturbance, anemia, nutrition, activity level, medication side effects, and other comorbidities.
It was noted that fatigue often occurs as part of a symptom cluster, often with sleep disturbance, emotional distress, or pain, so that assessment of these problems and institution of effective treatment is essential.
The importance of comprehensive assessment, including review of all current medications and noncancer comorbidities, was identified. For example, it was noted that there can be thyroid dysfunction after radiation therapy for various cancers or use of biological and that hypogonadism can be associated with fatigue.
National Comprehensive Cancer Network. (2012). NCCN clinical practice guidelines in oncology: Distress management [v.2.2013]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/distress.pdf
To provide clinical practice guidelines for the evaluation and treatment of distress — a normal feeling of vulnerability to a feeling that leads to disabling problems, such as depression and anxiety — in adult patients with cancer
Results were not stated.
Recommended standards of care include
Evaluation should include measures relating to level of distress, behavior symptoms, psychiatric history and medications, pain and symptom control, body image and sexuality issues, impaired capacity, safety, potential medical causes, and psychological disorders.
Management algorithms should be provided for dementia, delirium, mood disorder, psychotic disorder, adjustment disorder, anxiety disorder, personality disorder, and substance-related disorder.
Treatments identified for use include psychotherapy, anxiolytics, antidepressants, psychoeducation, cognitive behavioral therapy, social work and counseling interventions, spiritual counseling and ethics, and palliative care consultation according to algorithms.
The guidelines provide recommended pathways regarding assessment and management of distress. They do not provide a nursing perspective or identify a role for nursing in patient management.
RESOURCE TYPE: Consensus-based guideline
PHASE OF CARE: Not specified or not relevant
Limited information on the quality of evidence was retrieved. All recommendations were mainly consensus based.
This guideline provides very general level treatment algorithms based on the results of an initial distress screening, and recommends further assessment and intervention determination if overall distress is 4 or above on the distress thermometer.
National Comprehensive Cancer Network. (2011). NCCN Clinical Practice Guidelines in Oncology: Adult cancer pain [v. 2.2011]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf
The guidelines recommend the following for management of opioid-induced constipation.
Preventive Measures:
If Constipation Occurs:
Persistent Constipation:
Recommendations were identified as having low-level evidence and uniform consensus.
National Comprehensive Cancer Network. (2011). NCCN Clinical Practice Guidelines in Oncology: Adult cancer pain [v. 2.2011]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf
These guidelines do not provide any information about search strategy or any specific evaluation of evidence. Notes state that most direct evidence is of low quality, but recommendations do result from unanimous consensus.
The guidelines provide detailed recommendations regarding:
In general, opioids are first-line interventions. The NCCN guidelines suggest that antidepressants and anticonvulsants can be first-line treatments for adjuvant pain, although the recommendation for using them as such is still based on anecdotal experience or guidelines relating to patients who do not have cancer.
The NCCN guidelines provide comprehensive algorithms for pain management, from screening to ongoing maintenance. The guidelines recommend considering a variety of nonpharmacologic interventions. Psychosocial support, including coping-skills training, is recommended, as is comprehensive patient and family education. The guidelines provide useful information and an overview of the full range of pain management. The work points to the ongoing need to consider multiple adjuvant and supportive interventions to achieve pain relief that works for the individual patient.
National Comprehensive Cancer Network.( 2011). NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain [v.2.2011]. Retrieved from http://www.nccn.org/professionals/physician_gls/f_guidelines.asp
NCCN categories of evidence and consensus are described. Unless otherwise stated, all recommendations are reported to be category 2A, indicating a low level of evidence and uniform NCCN consensus. Specific process for evidence rating and consensus development is not described in the document. In addition, a search strategy was not described.
The NCCN guidelines document recommends universal screening for pain and provides an algorithm for comprehensive assessment and management approaches based on etiology of pain and current status with regard to pharmacologic management.
For opioid-naïve patients:
For opioid-tolerant patients:
For all cases, recommendations include:
For specific pain syndromes:
The major limitations of these guidelines are:
The NCCN guidelines document provides comprehensive decision making algorithms for assessment, severity grading, and management of cancer-related pain. The guidelines also provide assessment tools, titration schedule examples, and conversion tables for medications and conversion to transdermal fentanyl. An additional offering are suggestions regarding the management of a variety of opioid adverse effects. (A trial of adjunctive medications are suggested for neuropathic pain as a pain management approach.)
National Comprehensive Cancer Network. (2016). NCCN Clinical Practice Guidelines in Oncology: Antiemesis [v.2.2016]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf
RESOURCE TYPE: Evidence-based guideline
PHASE OF CARE: Multiple phases of care
One hundred seventy-one articles were retrieved via aPubMed search. No information was provided regarding which articles were selected as relevant to these guidelines, and no discussion of any method used for rating the quality of included evidence exists.
Limited database used. Recommendations are a combination of evidence- and consensus-based suggestions, and most nonpharmacologic interventions are by consensus.
Provides multiple evidence- and consensus-based recommendations for prophylaxis and the management of nausea and vomiting due to chemotherapy or radiation therapy. Recommendations provide a list of chemotherapy agents, including oral agents and categorization as to emetic potential.