CLINICAL PRACTICE GUIDELINES Connective Tissue Oncology Society 2005 Meeting, Boca Raton Vivien Bramwell Chair, NCIC-CTG Sarcoma Committee Canadian Sarcoma Group

CTOS CPG Canada Health Act Federal mandate Provincial delivery of services Canadian Strategy for Cancer Control (CSCC) RepresentationNCIC CCS CIHR CAPCA CCAN PHAC Council Chair: Dr. S. Sutcliffe Interprovincial Drug Strategies & Guidelines Group (IPDSGG) Links toProgram in Evidence-Based Care (Ontario) BC Cancer Agency CPG (British Columbia)

CTOS CPG Program in Evidence-Based Care (PEBC) Supported by Cancer Care Ontario Ontario Ministry of Health htpp:// 14 Disease Site/Discipline Groups ProducePractice Guidelines Evidence Summaries Sarcoma Group Chair1994 – 2000V. Bramwell(London) 2000  S. Verma(Ottawa)

CTOS CPG PEBCCore activity is development of PG by multidisciplinary DSG using methodology of Practice Guidelines Development Cycle* FormatQuestions Patient population Choice of topic and rationale Methods Results (includes quantatative meta-analysis) Interpretive Summary Ongoing trials Disease Site Group Consensus Process External Review of Practice Guideline Report Practice Guideline Journal Reference Acknowledgements References *Browman G et al J. Clin. Oncol. 13: 502, 1993

CTOS CPG CPG 11-1 (Original: Nov. 1999, Update: July 2004) This recommendation applies to adult patients with symptomatic unresectable locally advanced or metastatic STS who are candidates for palliative chemotherapy: Recommendation single agent doxorubicin is an appropriate first-line chemotherapy option for advanced or metastatic soft tissue sarcoma. Some doxorubicin-based combination chemotherapy regimens, given in conventional doses, produce only marginal increases in response rates at the expense of increased toxic effects, and no improvements in overall survival

CTOS CPG CPG 11-2 (Original: Nov. 2000, Update: Feb. 2005) These recommendations apply to adult patients with resected soft tissue sarcoma Recommendations it is reasonable to consider anthracycline-based adjuvant chemotherapy in patients who have had removal of a sarcoma with features predicting a high likelihood of relapse (deep location, size > 5 cm, high histological grade). These features correspond to UICC Stage III although the benefits of adjuvant chemotherapy are most apparent in patients with extremity sarcomas (7% risk difference [RD] for overall survival at 10 years), patients with high-risk tumors at other sites should also be considered for such therapy NB: Several qualifying statements

CTOS CPG PEBC Sarcoma DSG Draft CPG PG 11.3Localized treatment of extremity soft tissue sarcoma *PG 11.4Ifosfamide-based combination chemotherapy in advanced soft tissue sarcoma *PG 11.5Dose-intensive chemotherapy with growth factor or autologous marrow/stem cell support in advanced soft tissue sarcoma *PG 11.7Imatinib mesylate (Gleevec  ) for the treatment of adult patients with unresectable or metastatic gastrointestinal stromal tumors (GIST) PG 11.8Adjuvant radiotherapy for retroperitoneal sarcoma * completion November 2005

CTOS CPG British Columbia Cancer Agency (BCCA) htpp:// Health Professionals - Cancer Management Guidelines Based on accumulated experiences of BCCA together with “best” practice evidence derived from major cancer centres throughout the world Developed by Tumor Groups: oncologists, radiologists, pathologists, oncology nurses, pharmacists, other practitioners from health disciplines contributing to oncology care at BCCA & U of BC

CTOS CPG BCCA Cancer Management Guidelines Musculoskeletal & Sarcoma 01.Surgical management of sarcoma 02.Surgical management of metastatic disease 03.Special surgical considerations Retroperitoneal GIST Cystosarcoma phyllodes Dermatofibrosarcoma protuberans 04.Radiotherapy 05.Chemotherapy Curative Palliative 06.Combined multi-modality treatment for specific Ewing’s/small round blue cell Osteosarcoma (+ MFH bone, other high-grade spindle) Rhabdomyosarcomas Adjuvant chemotherapy for other STS Follow-up