clinical practice guideline

Locally Advanced, Unresectable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline.

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PURPOSE: To provide evidence-based recommendations to oncologists and others for treatment of patients with locally advanced, unresectable pancreatic cancer.

METHODS: American Society of Clinical Oncology convened an Expert Panel of medical oncology, radiation oncology, surgical oncology, gastroenterology, palliative care, and advocacy experts and conducted a systematic review of the literature from January 2002 to June 2015. Outcomes included overall survival, disease-free survival, progression-free survival, and adverse events.

RESULTS: Twenty-six randomized controlled trials met the systematic review criteria.

RECOMMENDATIONS: A multiphase computed tomography scan of the chest, abdomen, and pelvis should be performed. Baseline performance status and comorbidity profile should be evaluated. The goals of care, patient preferences, psychological status, support systems, and symptoms should guide decisions for treatments. A palliative care referral should occur at first visit. Initial systemic chemotherapy (6 months) with a combination regimen is recommended for most patients (for some patients radiation therapy may be offered up front) with Eastern Cooperative Oncology Group performance status 0 or 1 and a favorable comorbidity profile. There is no clear evidence to support one regimen over another. The gemcitabine-based combinations and treatments recommended in the metastatic setting (eg, fluorouracil, leucovorin, irinotecan, and oxaliplatin and gemcitabine plus nanoparticle albumin-bound paclitaxel) have not been evaluated in randomized controlled trials involving locally advanced, unresectable pancreatic cancer. If there is local disease progression after induction chemotherapy, without metastasis, then radiation therapy or stereotactic body radiotherapy may be offered also with an Eastern Cooperative Oncology Group performance status ≤ 2 and an adequate comorbidity profile. If there is stable disease after 6 months of induction chemotherapy but unacceptable toxicities, radiation therapy may be offered as an alternative. Patients with disease progression should be offered treatment per the ASCO Metastatic Pancreatic Cancer Treatment Guideline. Follow-up visits every 3 to 4 months are recommended.

Adult Sinusitis Guidelines Updated

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The American Academy of Otolaryngology–Head and Neck Surgery Foundation has presented an updated clinical practice guideline on adult sinusitis, with a greater focus on patient education and patient preference, published April 1 in Otolaryngology–Head and Neck Surgery.

In the United States, sinusitis affects approximately 1 in 8 adults, with more than 30 million diagnoses and $11 billion in direct costs per year. More than 1 in 5 antibiotics prescribed in adults are for sinusitis.
“More than ever before, there is a prominent role for shared decision-making between patients and clinicians when managing adult sinusitis — especially in deciding whether to use antibiotics for acute bacterial sinusitis or to instead try ‘watchful waiting’ to see if a patient can fight the infection on his or her own,” guidelines chair Richard M. Rosenfeld, MD, MPH, said in a news release.

The update recommends watchful waiting for initial management of all patients with uncomplicated acute bacterial rhinosinusitis, regardless of severity, and not just for those with “mild” illness, as in the 2007 guideline.

“Intuitively clinicians often feel that sicker patients benefit more from antibiotics, but our recommendation is that watchful waiting or antibiotics are both appropriate,” Dr Rosenfeld said. “This empowers patients and clinicians to use antibiotic judiciously, reserving antibiotics for cases that get worse or don’t improve over time.”

Another area benefitting from shared decision making is choice of symptomatic treatment, including analgesics, topical intranasal steroids, and nasal saline irrigation. The update includes a new algorithm to clarify decision-making and action statement relationships.

A multidisciplinary panel of experts in otolaryngology–head and neck surgery, infectious disease, family medicine, allergy and immunology, advanced practice nursing, and a consumer advocate updated this clinical guideline based on current evidence.

Additional changes from the 2007 guideline to the 2015 update include:

The addition of additional information regarding the role of analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of acute bacterial sinusitis.

Changed recommendation for the preferred agent when antibiotics are prescribed. The 2007 guideline called for amoxicillin alone, whereas the 2015 update recommends amoxicillin with or without clavulanate.

Inclusion of several recommendations for management of chronic rhinosinusitis, which was not addressed in the 2007 guideline. These include addition of asthma and of polyps as chronic conditions modifying chronic rhinosinusitis management, a recommendation for use of topical intranasal therapy (saline irrigations or corticosteroids), and a recommendation against using topical or systemic antifungal agents.

“The update group made strong recommendations that clinicians (1) should distinguish presumed [acute bacterial rhinosinusitis] from acute rhinosinusitis…caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of [chronic rhinosinusitis] with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography,” the authors write.