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Blood and bone marrow cancers

About

What is covered

This interactive flowchart covers managing 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

13 November 2018 Gemtuzumab ozogamicin for untreated acute myeloid leukaemia (NICE technology appraisal guidance 545) added to acute myeloid leukaemia.
18 September 2018 Inotuzumab ozogamicin for treating relapsed or refractory B-cell acute lymphoblastic leukaemia (NICE technology appraisal guidance 541) added to treatment for relapsed or refractory acute lymphoblastic leukaemia.
3 September 2018 Pembrolizumab for treating relapsed or refractory classical Hodgkin lymphoma (NICE technology appraisal guidance 540) added to Hodgkin lymphoma.
12 June 2018 Midostaurin for untreated acute myeloid leukaemia (NICE technology appraisal guidance 523) and arsenic trioxide for treating acute promyelocytic leukaemia (NICE technology appraisal guidance 526) added to acute myeloid leukaemia, and brentuximab vedotin for treating CD30-positive Hodgkin lymphoma (CDF review of TA446) (NICE technology appraisal guidance 524) added to Hodgkin lymphoma. Low-level laser therapy for preventing or treating oral mucositis caused by radiotherapy or chemotherapy (NICE interventional procedures guidance 615) added to possible complications of treatment.
7 November 2017 Venetoclax for treating chronic lymphocytic leukaemia (NICE technology appraisal guidance 487) added to first-line treatment for chronic lymphocytic leukaemia and treatment for relapsed or refractory chronic lymphocytic leukaemia. Recommendations in Hodgkin lymphoma amended after a change to the commercial arrangements for NICE's technology appraisal guidance on nivolumab for treating relapsed or refractory classical Hodgkin lymphoma. This change does not affect the cost effectiveness of nivolumab.
5 September 2017 Idelalisib with ofatumumab for treating chronic lymphocytic leukaemia (terminated appraisal) (NICE technology appraisal 469) added to first-line treatment for chronic lymphocytic leukaemia and treatment for relapsed or refractory chronic lymphocytic leukaemia, and ofatumumab with chemotherapy for treating chronic lymphocytic leukaemia (terminated appraisal) (NICE technology appraisal 470) added to treatment for relapsed or refractory chronic lymphocytic leukaemia.
25 July 2017 Nivolumab for treating relapsed or refractory classical Hodgkin lymphoma (NICE technology appraisal guidance 462) added to Hodgkin lymphoma.
4 July 2017 Ibrutinib for untreated chronic lymphocytic leukaemia without a 17p deletion or TP53 mutation (terminated appraisal) (NICE technology appraisal 452) added to first-line treatment for chronic lymphocytic leukaemia.
28 June 2017
31 May 2017 Haematological cancers (NICE quality standard 150) added.
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 myeloid leukaemia.
27 September 2016 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.
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.
24 May 2016 Haematological cancers: improving outcomes (NICE guideline NG47) added to service organisation.
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 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.

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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services 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 guideline should be interpreted in a way that would be inconsistent with complying 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.

Short Text

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

What is covered

This interactive flowchart covers managing 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

13 November 2018 Gemtuzumab ozogamicin for untreated acute myeloid leukaemia (NICE technology appraisal guidance 545) added to acute myeloid leukaemia.
18 September 2018 Inotuzumab ozogamicin for treating relapsed or refractory B-cell acute lymphoblastic leukaemia (NICE technology appraisal guidance 541) added to treatment for relapsed or refractory acute lymphoblastic leukaemia.
3 September 2018 Pembrolizumab for treating relapsed or refractory classical Hodgkin lymphoma (NICE technology appraisal guidance 540) added to Hodgkin lymphoma.
12 June 2018 Midostaurin for untreated acute myeloid leukaemia (NICE technology appraisal guidance 523) and arsenic trioxide for treating acute promyelocytic leukaemia (NICE technology appraisal guidance 526) added to acute myeloid leukaemia, and brentuximab vedotin for treating CD30-positive Hodgkin lymphoma (CDF review of TA446) (NICE technology appraisal guidance 524) added to Hodgkin lymphoma. Low-level laser therapy for preventing or treating oral mucositis caused by radiotherapy or chemotherapy (NICE interventional procedures guidance 615) added to possible complications of treatment.
7 November 2017 Venetoclax for treating chronic lymphocytic leukaemia (NICE technology appraisal guidance 487) added to first-line treatment for chronic lymphocytic leukaemia and treatment for relapsed or refractory chronic lymphocytic leukaemia. Recommendations in Hodgkin lymphoma amended after a change to the commercial arrangements for NICE's technology appraisal guidance on nivolumab for treating relapsed or refractory classical Hodgkin lymphoma. This change does not affect the cost effectiveness of nivolumab.
5 September 2017 Idelalisib with ofatumumab for treating chronic lymphocytic leukaemia (terminated appraisal) (NICE technology appraisal 469) added to first-line treatment for chronic lymphocytic leukaemia and treatment for relapsed or refractory chronic lymphocytic leukaemia, and ofatumumab with chemotherapy for treating chronic lymphocytic leukaemia (terminated appraisal) (NICE technology appraisal 470) added to treatment for relapsed or refractory chronic lymphocytic leukaemia.
25 July 2017 Nivolumab for treating relapsed or refractory classical Hodgkin lymphoma (NICE technology appraisal guidance 462) added to Hodgkin lymphoma.
4 July 2017 Ibrutinib for untreated chronic lymphocytic leukaemia without a 17p deletion or TP53 mutation (terminated appraisal) (NICE technology appraisal 452) added to first-line treatment for chronic lymphocytic leukaemia.
28 June 2017
31 May 2017 Haematological cancers (NICE quality standard 150) added.
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 myeloid leukaemia.
27 September 2016 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.
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.
24 May 2016 Haematological cancers: improving outcomes (NICE guideline NG47) added to service organisation.
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 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.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Gemtuzumab ozogamicin for untreated acute myeloid leukaemia (2018) NICE technology appraisal guidance 545
Arsenic trioxide for treating acute promyelocytic leukaemia (2018) NICE technology appraisal guidance 526
Midostaurin for untreated acute myeloid leukaemia (2018) NICE technology appraisal guidance 523
Venetoclax for treating chronic lymphocytic leukaemia (2017) NICE technology appraisal guidance 487
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
Haematological cancers (2017) NICE quality standard 150

Quality standards

Haematological cancers

These quality statements are taken from the haematological cancers quality standard. The quality standard defines clinical best practice for haematological cancers and should be read in full.

Quality statements

Integrated reporting

This quality statement is taken from the haematological cancers quality standard. The quality standard defines clinical best practice for managing haematological cancers and should be read in full.

Quality statement

People with haematological cancer have an integrated report produced by a specialist integrated haematological malignancy diagnostic service (SIHMDS) that is shared with the haemato-oncology multidisciplinary team (MDT).

Rationale

An integrated diagnostic report containing all the information relevant to managing a person’s condition is important to reduce duplication and avoid any contradictions that may arise when investigations are carried out in separate laboratories. Prompt sharing of integrated reports with the haemato-oncology MDT is vital for making decisions about management and will aid communication and co-working. However, when there is urgent clinical need, SIHMDS should release provisional laboratory reports before the integrated report is produced.

Quality measures

Structure
Evidence of local arrangements to ensure that people with haematological cancer have an integrated report produced by a SIHMDS, containing all clinical information relevant to management, that is shared with the haemato-oncology MDT.
Data source: Local data collection.
Process
a) Proportion of people with haematological cancer who have an integrated report produced by a SIHMDS.
Numerator – the number in the denominator who have an integrated report produced by a SIHMDS.
Denominator – the number of people with haematological cancer.
Data source: Local data collection.
b) Number of integrated reports produced by a SIHMDS that are shared with the haemato-oncology MDT.
Numerator – the number in the denominator that are shared with the haemato-oncology MDT.
Denominator – the number of SIHMDS integrated reports.
Data source: Local data collection.
Outcome
Discontinuation of treatment.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (specialist regional centres) ensure that organisations and departments take responsibility for establishing appropriate management structures that oversee laboratory processes and the quality of diagnostic reporting, and audit the production of SIHMDS-validated integrated reports for people with haematological cancers and the sharing of these with the haemato-oncology MDT.
Healthcare professionals (such as the SIHMDS director and the SIHMDS haematopathologist) are responsible for reporting standards and overseeing the production of the integrated reports that include all the diagnostic information relevant to managing haematological cancers. These reports are shared with the haemato-oncology MDT. The haematopathologist establishes the order in which the different results are included in the report and presented to the MDT, and can explain the report.
Commissioners (such as clinical commissioning groups) ensure that they commission services in which SIHMDS produce validated integrated reports for people with haematological cancers and share them with the relevant haemato-oncology MDT.
People with blood cancer have all of their test results and other information about their diagnosis included in a single report that is shared with their specialist team.

Source guidance

Haematological cancers: improving outcomes (2016) NICE guideline NG47, recommendations 1.1.2 and 1.1.3

Definitions of terms used in this quality statement

Integrated report
A single IT system-generated report summarising all elements of laboratory diagnosis for a specific patient episode, based on available results for haematological cytology, histopathology, immunophenotyping by flow cytometry, cytogenetics, fluorescence in situ hybridisation (FISH) and molecular genetics, in accordance with the current WHO diagnostic classification. A process for validating the report, including double-reporting, and internal audit and cross-checking of results, is recommended before final authorisation.
[Adapted from NICE’s guideline on haematological cancers, addendum and recommendations 1.1.3, 1.1.4, 1.1.8 and 1.1.9]
Haemato-oncology MDT
Each haemato-oncology MDT should include sufficient core members for the following people to be present in person or remotely (for example, via video conferencing) at every meeting:
  • Haemato-oncologists (either haematologists or some medical oncologists): at least two who specialise in each tumour type being discussed at that meeting (for example, leukaemia or lymphoma) and at least one from each hospital site contributing to the MDT.
  • Haematopathologist: at least one haematopathologist from the SIHMDS should be present to provide the diagnostic information.
  • Nurses: at least one clinical nurse specialist, also ward sisters from hospitals that provide high intensity chemotherapy.
  • Palliative care specialist: at least one palliative care specialist (doctor or nurse) who liaises with specialists from other sites. If, because of staff shortages or location, a palliative care specialist cannot regularly attend MDT meetings, the MDT should be able to demonstrate that it reviews patients regularly with such a specialist.
  • Support staff: staff to organise team meetings and provide secretarial support.
Teams established to manage people with lymphoma should include the following additional core members, who should be fully and regularly involved in MDT discussions:
  • Clinical oncologist: at least one.
  • Radiologist: at least one, who liaises with radiologists at other sites.
Teams responsible for managing people with myeloma should include at least one radiologist who liaises with radiologists at other sites and is fully and regularly involved in MDT discussions. Teams that care for people with myeloma should have rapid access to oncologists for palliative radiotherapy, although it is not necessary for clinical oncologists to regularly attend team meetings.
[Adapted from NICE’s guideline on haematological cancers, recommendations 1.3.9, 1.3.10 and 1.3.11]

Staging using FDG-PET-CT

This quality statement is taken from the haematological cancers quality standard. The quality standard defines clinical best practice for managing haematological cancers and should be read in full.

Quality statement

Young people and adults with specific subtypes of non-Hodgkin’s lymphoma have staging using fluorodeoxyglucose-positron emission tomography-CT (FDG-PET-CT).

Rationale

Imaging before treatment is important to define the disease stage and enable appropriate therapy. Metabolic imaging with FDG-PET-CT is more accurate than CT imaging alone for detecting the disease site in several specific histological subtypes of non-Hodgkin’s lymphoma.

Quality measures

Structure
Evidence of local arrangements to ensure that young people and adults with specific subtypes of non-Hodgkin’s lymphoma have staging using FDG-PET-CT.
Data source: Local data collection.
Process
a) Proportion of young people and adults with stage I diffuse large B-cell lymphoma who have staging using FDG-PET-CT.
Numerator – the number in the denominator who have staging using FDG-PET-CT.
Denominator – the number of young people and adults with stage I diffuse large B-cell lymphoma.
Data source: Local data collection.
b) Proportion of young people and adults with stage I or localised stage II follicular lymphoma for whom radiotherapy would be technically possible who have staging using FDG-PET-CT.
Numerator – the number in the denominator who have staging using FDG-PET-CT.
Denominator – the number of young people and adults with stage I or localised stage II follicular lymphoma for whom radiotherapy would be technically possible.
Data source: Local data collection.
c) Proportion of young people and adults with stage I or II Burkitt lymphoma with other low-risk features who have staging using FDG-PET-CT.
Numerator – the number in the denominator who have staging using FDG-PET-CT.
Denominator – the number of young people and adults with stage I or II Burkitt lymphoma with other low-risk features.
Data source: Local data collection.
Outcome
a) Number of young people and adults with specific subtypes of non-Hodgkin’s lymphoma who have accurate staging.
Data source: Local data collection.
b) Treatment appropriate to the subtype of non-Hodgkin’s lymphoma.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (specialist regional centres) have processes in place to ensure that young people and adults with specific subtypes of non-Hodgkin’s lymphoma have FDG-PET-CT for staging.
Healthcare professionals (such as clinical oncologists) use FDG-PET-CT for accurate staging of specific subtypes of non-Hodgkin’s lymphoma in young people and adults.
Commissioners (clinical commissioning groups) ensure that they commission services in which young people and adults with specific subtypes of non-Hodgkin’s lymphoma have FDG-PET-CT for staging.
Young people and adults with certain types of non-Hodgkin’s lymphoma have a special scan called a FDG-PET-CT scan to show where the cancer cells are in the body and confirm the stage of the cancer. FDG-PET-CT scans are particularly useful for people who have been diagnosed with types of lymphoma called large B-cell lymphoma, follicular lymphoma and Burkitt lymphoma.

Source guidance

Non-Hodgkin's lymphoma: diagnosis and management (2016) NICE guideline NG52, recommendation 1.2.1

Definitions of terms used in this quality statement

Young people and adults
16 years and over.
Specific subtypes of non-Hodgkin’s lymphoma
FDG-PET-CT imaging should be offered to young people and adults with:
  • stage I diffuse large B cell lymphoma
  • stage I or localised stage II follicular lymphoma for whom radiotherapy would be technically possible (if the disease is thought to be encompassable within a radiotherapy field)
  • stage I or II Burkitt lymphoma with other low risk features.
[Adapted from NICE’s guideline on Non-Hodgkin's lymphoma: diagnosis and management recommendation 1.2.1]

First-line treatment for localised stage IIA follicular lymphoma

This quality statement is taken from the haematological cancers quality standard. The quality standard defines clinical best practice for managing haematological cancers and should be read in full.

Quality statement

Young people and adults with localised stage IIA follicular lymphoma have local radiotherapy as first-line treatment.

Rationale

Localised radiotherapy is the most effective first treatment for young people and adults with localised stage IIA follicular lymphoma. It has low toxicity and has the potential to cure a minority of young people and adults with this type of lymphoma.

Quality measures

Structure
Evidence of local arrangements to ensure that young people and adults with localised stage IIA follicular lymphoma have local radiotherapy as first-line treatment.
Data source: Local data collection.
Process
Proportion of young people and adults with localised stage IIA follicular lymphoma who receive local radiotherapy as first-line treatment.
Numerator – the number in the denominator who receive local radiotherapy as first-line treatment.
Denominator – the number of young people and adults with localised stage IIA follicular lymphoma.
Data source: National Radiotherapy Dataset and local data collection.
Outcome
Survival rates for young people and adults with localised stage IIA follicular lymphoma.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (secondary care NHS hospital trusts) have processes in place to ensure that young people and adults with localised stage IIA follicular lymphoma are referred to radiotherapy services, which provide local radiotherapy for first-line treatment of lymphoma.
Healthcare professionals (such as clinical oncologists) perform local radiotherapy as first-line treatment for young people and adults with localised stage IIA follicular lymphoma.
Commissioners (clinical commissioning groups) ensure that they commission services in which young people and adults with localised stage IIA follicular lymphoma have local radiotherapy as first-line treatment for lymphoma.
Young people and adults with stage 2A follicular lymphoma in one area of the body (‘localised’) have radiotherapy focused on that area as their first treatment option.

Source guidance

Non-Hodgkin's lymphoma: diagnosis and management (2016) NICE guideline NG52, recommendation 1.3.1

Definition of terms used in this quality statement

Young people and adults
16 years and over.

End-of-treatment summary plan

This quality statement is taken from the haematological cancers quality standard. The quality standard defines clinical best practice for managing haematological cancers and should be read in full.

Quality statement

Young people and adults who have completed their treatment for non-Hodgkin’s lymphoma or myeloma have a discussion about their end-of-treatment summary plan.

Rationale

Discussing the end-of-treatment summary plan with a person who has had treatment supports self-management and awareness of signs or symptoms of disease recurrence. It can also alert people to some of the possible late effects of their treatment and possible long-term psychological and emotional problems, such as depression and anxiety, which can occur after treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that young people and adults who have had treatment for non-Hodgkin’s lymphoma or myeloma have a discussion about their end-of-treatment summary plan when they complete their treatment.
Data source: Local data collection.
Process
a) Proportion of young people and adults who have completed their treatment for non-Hodgkin’s lymphoma and who have a discussion about their end-of-treatment summary plan.
Numerator – the number in the denominator who have a discussion about their end-of-treatment summary plan.
Denominator – the number of young people and adults who have completed their treatment for non-Hodgkin’s lymphoma.
Data source: Local data collection.
b) Proportion of young people and adults who have completed their treatment for myeloma and who have a discussion about their end-of-treatment summary plan.
Numerator – the number in the denominator who have a discussion about their end-of-treatment summary plan.
Denominator – the number of young people and adults who have completed their treatment for myeloma.
Data source: Local data collection.
Outcome
a) Young people and adults with non-Hodgkin’s lymphoma or myeloma feel supported to self-manage their condition.
Data source: Local data collection.
b) Early identification of treatment-related morbidity in young people and adults with non-Hodgkin’s lymphoma or myeloma.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (specialist regional centres) ensure that processes are in place for young people and adults with non-Hodgkin’s lymphoma or myeloma to discuss their end-of-treatment summary plan with a member of their haemato-oncology multidisciplinary team (MDT).
Healthcare professionals (such as clinical nurse specialists and other members of the haemato-oncology MDT) have a discussion with young people and adults with non-Hodgkin’s lymphoma or myeloma about their end-of-treatment summary plan, highlighting personal and general risk factors, including late effects related to their lymphoma subtype, myeloma or its treatment.
Commissioners (clinical commissioning groups) ensure that they commission services in which young people and adults with non-Hodgkin’s lymphoma or myeloma discuss their end-of-treatment summary plan with a member of their haemato-oncology MDT.
Young people and adults who have finished their treatment for non-Hodgkin’s lymphoma or myeloma discuss their end-of-treatment summary plan with a member of their specialist team. This includes explaining the tests and treatments the person had and whether there may be ongoing side effects or side effects that may appear months or even years after treatment. It also includes how to spot signs that might suggest the cancer is coming back.

Source guidance

Definitions of terms used in this quality statement

Young people and adults
16 years and over.
End-of-treatment summary plan
Includes personal and general risk factors, such as late effects related to lymphoma subtype, myeloma and/or its treatment as follows:
  • heart damage
  • peripheral neuropathy
  • cognitive disorders
  • second cancers
  • infertility
  • endocrine (hormonal) problems
  • bone and joint damage
  • chronic tiredness
  • lifestyle factors – exercise, diet and smoking
  • inability to do day-to-day tasks.
[Adapted from NICE’s guideline on non-Hodgkin's lymphoma, full guideline and recommendation 1.11.1]

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Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services 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 guideline should be interpreted in a way that would be inconsistent with complying 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.

Supporting information

Rationale: gemtuzumab ozogamicin

AML is currently treated with daunorubicin plus cytarabine. Cytogenetic testing is used to look for specific gene mutations in certain types of leukaemia, which might predict how a person's disease responds to treatment and affect treatment options. People whose disease has favourable or intermediate cytogenetics have a better prognosis than those whose disease has unfavourable cytogenetics in terms of treatment response, risk of relapse and survival. However, for some patients the cytogenetic test results are not available at the start of induction treatment.
Evidence from a randomised clinical trial shows that, for people whose disease has favourable or intermediate cytogenetics, gemtuzumab ozogamicin with daunorubicin and cytarabine is more clinically effective than daunorubicin and cytarabine. People are more likely to live longer without the disease relapsing or symptoms returning.
Because no clinical or cost-effectiveness analysis is presented for people whose disease has unfavourable cytogenetics, gemtuzumab ozogamicin cannot be recommended for this group.
The most plausible cost-effectiveness estimates (including the stopping rule for consolidation therapy in people who have unfavourable cytogenetics) for gemtuzumab ozogamicin compared with daunorubicin and cytarabine in people whose disease has favourable, intermediate or unknown cytogenetics (because the cytogenetic test is unsuccessful) are within the range that NICE normally considers an acceptable use of NHS resources. Therefore gemtuzumab ozogamicin can be recommended for these groups of people.
For more information see the committee discussion in the NICE technology appraisal guidance on gemtuzumab ozogamicin for untreated acute myeloid leukaemia.

Rationale: pembrolizumab

The marketing authorisation for pembrolizumab includes 2 subpopulations of people with relapsed or refractory classical Hodgkin lymphoma: people who have had brentuximab vedotin and autologous stem cell transplant and those who have had brentuximab vedotin but cannot have autologous stem cell transplant.
There is no evidence directly comparing pembrolizumab with current standard care in either of the subpopulations. Indirect analyses suggest that having pembrolizumab after brentuximab vedotin may lead to longer progression-free survival than current treatment. This would increase the number of people who can have curative allogeneic stem cell transplant. It is uncertain how many people having pembrolizumab will be able to have allogeneic stem cell transplant and their long-term outcomes compared with those having standard care and this is a key driver of cost effectiveness.
NICE recommends nivolumab for treating relapsed or refractory classical Hodgkin lymphoma in adults after autologous stem cell transplant and brentuximab vedotin. The committee heard from clinical experts that the clinical effectiveness of pembrolizumab and nivolumab are likely to be similar in this population. The company did not provide a cost-comparison between pembrolizumab and nivolumab and so the committee based its decision on the cost effectiveness of pembrolizumab compared with standard care before the introduction of nivolumab.
Pembrolizumab meets NICE's criteria to be considered a life-extending treatment at the end of life.
Because of uncertainties in the clinical effectiveness and the modelling, the cost-effectiveness estimates are uncertain. Because of this, pembrolizumab cannot be recommended for routine use in the NHS.
There is an unmet treatment need for people who have had brentuximab vedotin and cannot have autologous stem cell transplant. There are no licensed immunotherapies for this subpopulation. Pembrolizumab has plausible potential to be cost effective for people who cannot have autologous stem cell transplant. Further data collection may reduce the uncertainty about the cost effectiveness. Therefore pembrolizumab is recommended for use in the Cancer Drugs Fund for people who have classical Hodgkin lymphoma that has relapsed after, or not responded to, brentuximab vedotin and who cannot have autologous stem cell transplant.
For more information see the committee discussion in the NICE technology appraisal guidance on pembrolizumab for treating relapsed or refractory classical Hodgkin lymphoma.

Rationale: midostaurin

Treatment for acute myeloid leukaemia is chemotherapy. Evidence from a randomised controlled trial shows that people taking midostaurin with chemotherapy live longer than people taking chemotherapy alone.
There is uncertainty about the cost effectiveness of midostaurin because of problems with the economic model. But with the most plausible model assumptions and the discounted price, the cost-effectiveness estimates of midostaurin plus chemotherapy compared with chemotherapy alone are within the range that NICE normally considers a cost-effective use of NHS resources, so midostaurin is recommended.
For more information see the committee discussion in the NICE technology appraisal guidance on midostaurin for untreated acute myeloid leukaemia.

Rationale: brentuximab vedotin

NICE technology appraisal guidance 446

Hodgkin lymphoma is usually treated with chemotherapy, followed by stem cell transplant. Stem cell transplant gives people the best chance of a cure, so people who cannot have stem cell transplant have a high clinical unmet need. Brentuximab vedotin can be used as a 'bridging' treatment before stem cell transplant and, in some cases, as a curative treatment itself.
NICE technology appraisal guidance 446 recommended brentuximab vedotin as an option for treating adults with relapsed or refractory CD30-positive Hodgkin lymphoma after autologous stem cell transplant. However, it was not recommended for adults who are at increased risk of disease relapse or progression after autologous stem cell transplant because the cost-effectiveness estimates were too high.
For adults with relapsed or refractory disease after at least 2 previous therapies, when autologous stem cell transplant or multi-agent chemotherapy is not suitable, the cost-effectiveness evidence was less clear. So brentuximab vedotin was recommended for use within the Cancer Drugs Fund in this population to collect data on its effectiveness in practice.

Cancer Drugs Fund Review of technology appraisal guidance 446

In this Cancer Drugs Fund review of technology appraisal guidance 446, data collected through the Cancer Drugs Fund on rates of stem cell transplant after treatment with brentuximab vedotin show that it improved rates of stem cell transplant compared with chemotherapy. Also, the updated cost-effectiveness estimates for brentuximab vedotin are lower than £20,000 per quality-adjusted life year gained. Because of this, brentuximab vedotin is recommended as an option for treating relapsed or refractory CD30-positive Hodgkin lymphoma in adults, only if they have already had autologous stem cell transplant, or at least 2 previous therapies when autologous stem cell transplant or multi-agent chemotherapy are not suitable.
For more information see the committee discussion in the NICE technology appraisal guidance on brentuximab vedotin for treating CD30-positive Hodgkin lymphoma (CDF review of TA446).

Rationale: arsenic trioxide

People with untreated, low-to-intermediate risk acute promyelocytic leukaemia are given ATRA plus chemotherapy (together called AIDA). Clinical trial evidence shows that arsenic trioxide plus ATRA is effective for untreated disease compared with AIDA. Some assumptions in the model, such as the costs of stem cell transplant and the long-term effect of treatment, lead to the cost-effectiveness analyses being uncertain. However, the most plausible cost-effectiveness estimate is likely to be less than £20,000 per quality-adjusted life year gained, so arsenic trioxide plus ATRA is cost effective compared with AIDA in untreated disease.
Arsenic trioxide is already used to treat relapsed or refractory acute promyelocytic leukaemia. The clinical- and cost-effectiveness evidence for arsenic trioxide in relapsed or refractory disease is uncertain, because the clinical trial was small and did not compare arsenic trioxide with AIDA. However, it is likely that arsenic trioxide is clinically effective and represents a cost-effective use of NHS resources in relapsed or refractory disease. Therefore, arsenic trioxide is recommended for both untreated and relapsed or refractory disease.
For more information see the committee discussion in the NICE technology appraisal guidance on arsenic trioxide for treating acute promyelocytic leukaemia.

Rationale: inotuzumab ozogamicin

Treatment for relapsed or refractory B-cell acute lymphoblastic leukaemia is usually fludarabine, cytarabine and granulocyte colony-stimulating factor based chemotherapy (FLAG) with idarubicin. People with Philadelphia-chromosome-positive disease can have FLAG-based therapy with tyrosine kinase inhibitors or tyrosine kinase inhibitors alone. Clinical trial evidence does not show an overall survival benefit for people having inotuzumab ozogamicin compared with those having FLAG, high-dose cytarabine or cytarabine with mitoxantrone-based chemotherapy. However, more people having inotuzumab ozogamicin are able to go on to have a stem cell transplant when compared with people having the other treatments. Inotuzumab ozogamicin also meets NICE's criteria to be a life-extending treatment at the end of life.
The most plausible cost-effectiveness estimates for inotuzumab ozogamicin compared with standard care are in the range NICE considers an acceptable use of NHS resources. Therefore it can be recommended for treating relapsed or refractory B-cell acute lymphoblastic leukaemia.
For more information see the committee discussion in the NICE technology appraisal guidance on inotuzumab ozogamicin for treating relapsed or refractory B-cell acute lymphoblastic leukaemia.
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

acute myeloid leukaemia
specialist integrated haematological malignancy diagnostic services
World Health Organization

Paths in this pathway

Pathway created: December 2013 Last updated: November 2018

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