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Blood and bone marrow cancers

About

What is covered

This interactive flowchart includes guidance on leukaemia and improving outcomes for people with blood and bone marrow cancers.
To find other information about blood and bone marrow cancers, including evidence from NICE Accredited sources, visit NICE Evidence Search.

Updates

Updates to this interactive flowchart

21 March 2017 Ibrutinib with bendamustine and rituximab for treating relapsed or refractory chronic lymphocytic leukaemia after systemic therapy (terminated appraisal) (NICE technology appraisal 437) added to treatment for relapsed or refractory chronic lymphocytic leukaemia.
24 January 2017 Ibrutinib for previously treated chronic lymphocytic leukaemia and untreated chronic lymphocytic leukaemia with 17p deletion or TP53 mutation (NICE technology appraisal guidance 429) added to first-line treatment for chronic lymphocytic leukaemia and treatment for relapsed or refractory chronic lymphocytic leukaemia.
20 December 2016 Dasatinib, nilotinib and imatinib for untreated chronic myeloid leukaemia (NICE technology appraisal guidance 426) and dasatinib, nilotinib and high-dose imatinib for treating imatinib-resistant or intolerant chronic myeloid leukaemia (NICE technology appraisal guidance 425) added to the myeloid leukaemia path.
27 September 2016 Path on leukaemia divided into acute leukaemia and chronic leukaemia, and pegaspargase for treating acute lymphoblastic leukaemia (NICE technology appraisal guidance 408) added to first-line treatment for acute lymphoblastic leukaemia.
23 August 2016 Bosutinib for previously treated chronic myeloid leukaemia (NICE technology appraisal guidance 401) added to myeloid leukaemia path.
26 July 2016 Azacitidine for treating acute myeloid leukaemia with more than 30% bone marrow blasts (NICE technology appraisal guidance 399) added to azacitidine for people with acute myeloid leukaemia who are ineligible for stem cell transplants.
19 July 2016 Path on non-Hodgkin's lymphoma replaced by a link to NICE's interactive flowchart on non-Hodgkin's lymphoma.
24 May 2016 Haematological cancers: improving outcomes (NICE guideline NG47) added to service organisation.
24 March 2016 European Medicines Agency new safety monitoring procedures for idelalisib added to leukaemia path.
15 March 2016 Path on multiple myeloma replaced by a link to NICE's interactive flowchart on myeloma.
27 October 2015 Idelalisib for treating chronic lymphocytic leukaemia (NICE technology appraisal guidance 359) added to first-line treatment for chronic lymphocytic leukaemia and treatment for relapsed or refractory chronic lymphocytic leukaemia.
22 September 2015 Ruxolitinib for treating polycythaemia vera (terminated appraisal) (NICE technology appraisal 356) added to new node polycythaemia vera.
1 June 2015 Obinutuzumab in combination with chlorambucil for untreated chronic lymphocytic leukaemia (NICE technology appraisal guidance 343) and ofatumumab in combination with chlorambucil or bendamustine for untreated chronic lymphocytic leukaemia (NICE technology appraisal guidance 344) added to first-line treatment for chronic lymphocytic leukaemia.
20 February 2014 Amended position of azacitidine for the treatment of myelodysplastic syndromes, chronic myelomonocytic leukaemia and acute myeloid leukaemia (NICE technology appraisal guidance 218) in the leukaemia path.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on blood and bone marrow cancers including leukaemia in an interactive flowchart

What is covered

This interactive flowchart includes guidance on leukaemia and improving outcomes for people with blood and bone marrow cancers.
To find other information about blood and bone marrow cancers, including evidence from NICE Accredited sources, visit NICE Evidence Search.

Updates

Updates to this interactive flowchart

21 March 2017 Ibrutinib with bendamustine and rituximab for treating relapsed or refractory chronic lymphocytic leukaemia after systemic therapy (terminated appraisal) (NICE technology appraisal 437) added to treatment for relapsed or refractory chronic lymphocytic leukaemia.
24 January 2017 Ibrutinib for previously treated chronic lymphocytic leukaemia and untreated chronic lymphocytic leukaemia with 17p deletion or TP53 mutation (NICE technology appraisal guidance 429) added to first-line treatment for chronic lymphocytic leukaemia and treatment for relapsed or refractory chronic lymphocytic leukaemia.
20 December 2016 Dasatinib, nilotinib and imatinib for untreated chronic myeloid leukaemia (NICE technology appraisal guidance 426) and dasatinib, nilotinib and high-dose imatinib for treating imatinib-resistant or intolerant chronic myeloid leukaemia (NICE technology appraisal guidance 425) added to the myeloid leukaemia path.
27 September 2016 Path on leukaemia divided into acute leukaemia and chronic leukaemia, and pegaspargase for treating acute lymphoblastic leukaemia (NICE technology appraisal guidance 408) added to first-line treatment for acute lymphoblastic leukaemia.
23 August 2016 Bosutinib for previously treated chronic myeloid leukaemia (NICE technology appraisal guidance 401) added to myeloid leukaemia path.
26 July 2016 Azacitidine for treating acute myeloid leukaemia with more than 30% bone marrow blasts (NICE technology appraisal guidance 399) added to azacitidine for people with acute myeloid leukaemia who are ineligible for stem cell transplants.
19 July 2016 Path on non-Hodgkin's lymphoma replaced by a link to NICE's interactive flowchart on non-Hodgkin's lymphoma.
24 May 2016 Haematological cancers: improving outcomes (NICE guideline NG47) added to service organisation.
24 March 2016 European Medicines Agency new safety monitoring procedures for idelalisib added to leukaemia path.
15 March 2016 Path on multiple myeloma replaced by a link to NICE's interactive flowchart on myeloma.
27 October 2015 Idelalisib for treating chronic lymphocytic leukaemia (NICE technology appraisal guidance 359) added to first-line treatment for chronic lymphocytic leukaemia and treatment for relapsed or refractory chronic lymphocytic leukaemia.
22 September 2015 Ruxolitinib for treating polycythaemia vera (terminated appraisal) (NICE technology appraisal 356) added to new node polycythaemia vera.
1 June 2015 Obinutuzumab in combination with chlorambucil for untreated chronic lymphocytic leukaemia (NICE technology appraisal guidance 343) and ofatumumab in combination with chlorambucil or bendamustine for untreated chronic lymphocytic leukaemia (NICE technology appraisal guidance 344) added to first-line treatment for chronic lymphocytic leukaemia.
20 February 2014 Amended position of azacitidine for the treatment of myelodysplastic syndromes, chronic myelomonocytic leukaemia and acute myeloid leukaemia (NICE technology appraisal guidance 218) in the leukaemia path.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Pegaspargase for treating acute lymphoblastic leukaemia (2016) NICE technology appraisal guidance 408
Bosutinib for previously treated chronic myeloid leukaemia (2016) NICE technology appraisal guidance 401
Idelalisib for treating chronic lymphocytic leukaemia (2015) NICE technology appraisal guidance 359
Guidance on the use of imatinib for chronic myeloid leukaemia (2003) NICE technology appraisal guidance 70

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

The Guideline Committee redefined levels 2b and 3 from the British Committee for Standards in Haematology (BCSH) guidelines on levels of care, and level 2 care from the original NICE cancer service guidance on improving outcomes in haematological cancers. The new definitions are based only on the depth and duration of expected severe neutropenia.
Low- to intermediate-intensity chemotherapy
All other chemotherapy not included in the definitions below.
High-intensity chemotherapy
Chemotherapy that is anticipated to result in severe neutropenia (0.5x109/litre or lower) for 7 or more days. In addition other potential organ toxicities, comorbidities and frailty should be considered. The relevant chemotherapy regimens are usually but not exclusively those used for curative treatment of acute myeloid leukaemia, high-risk myelodysplastic syndrome, acute lymphoblastic leukaemia, Burkitt lymphoma (and other rare aggressive lymphomas treated on Burkitt lymphoma-like protocols) and lymphoblastic lymphoma. Salvage treatments for other types of lymphoma would not usually be included in this definition.
Autologous and allogeneic haematopoietic stem cell transplantation (HSCT)
Previously referred to as high-dose therapy in the original 2003 NICE guidance on improving outcomes in haematological cancers. Commissioned centrally through specialised commissioning and a centre should meet FACT-JACIE accreditation standards.

Glossary

specialist integrated haematological malignancy diagnostic services
World Health Organization

Paths in this pathway

Pathway created: December 2013 Last updated: March 2017

© NICE 2017

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