Tutorial

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This page is intended for folks using HemOnc.org for the first time, although frequent visitors may also learn about new features here. What follows are descriptions of the main features of the wiki.


Table of contents

Almost every page of the wiki has a table of contents, which allows you to jump quickly to the area of the page that you are most interested in. On various longer pages (e.g. the chemotherapy regimen pages) there are also "back to top" buttons that will bring you back to the table of contents.

Main page

This is the landing page of HemOnc.org and is primarily a portal to get to the regimen pages, which are organized in three groups: 1) solid oncology; 2) malignant hematology; and 3) other hematology. There are also many links that appear on the left-hand side navigation bar, which will in fact appear on any page of the wiki.

Chemotherapy regimen pages

These are probably the pages you are going to visit the most. Chemotherapy regimens are grouped into individual pages by cancer histology, or sometimes by related histologies (for example, the sarcoma page has several distinctly different sarcoma histologies, including GIST). Although the inclusion of a regimen on a page is not an endorsement of its efficacy, we generally only include regimens that are either current, recommended by well-known guideline organizations (e.g. NCCN, ASCO), or claimed to be efficacious by their author(s). If you do not see the regimen that you are looking for, it is either:

  • missing and needs to be added to HemOnc.org;
  • intentionally left off the page for not meeting one or more of the criteria just mentioned; or
  • present on an "obsolete" regimens page.

We are still establishing the standards by which a regimen would be considered "obsolete"; please see this page as an example of the work in progress. Proposed definitions of obsolete are:

  • no longer recommended by any well-known guideline organization (e.g. NCCN, ASCO);
  • more than 10 years from initial publication without any additional updates;
  • no longer used in practice (obviously, difficult to prove!).

On a particular regimen page, regimens are listed alphabetically and by context; for example the melanoma page has two sections:

  1. adjuvant therapy
  2. metastatic or unresectable disease

On some pages, the regimens are further organized by whether or not they are described as part of a randomized trial or as a nonrandomized intervention or retrospective analysis. This results at times in the same regimen appearing under more than one section for the same context; this happens when a distinct variant is randomized whereas another is non-randomized. See for example the randomized variants of R-CHOP for follicular lymphoma versus the non-randomized variants.

Regimens

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When we use the term "regimen", we are broadly including any prescription with a disease modifying effect, and optionally additional prescriptions to manage the side effects of the disease-modifying agents (i.e., supportive medications). Since we are primarily focused on medical oncology and hematology, the majority of the regimens (or protocols; the words are interchangeable) have one or more antineoplastic or disease-modifying medications; we also have a few regimens that are radiotherapy-based. When describing a regimen, we try to use a consistent style for each chemotherapy regimen, so that you can find the information that you are looking for quickly and easily. Here are the components you will find:

Acronym

For regimens that are known by their acronym(s), the first thing we do is spell out the acronym. Since these acronyms often contain outdated or brand-names, we include the generic names in parentheses as indicated.

Example: CHOP: Cyclophosphamide, Hydroxydaunorubicin (Doxorubicin), Oncovin (Vincristine), Prednisone

Variant

The next thing we do is list each variant of a regimen that we have found, numerically. Right now the order is not really meant to mean anything, although that may change in the future; sometimes we have placed variants in reverse chronologic order of publication, for instance. Generally we consider a variant to be significantly different dosing, significantly different numbers of cycles, or substitution of a similar but not identical medication (e.g. CHOP with prednisolone substituted for prednisone).

Authorship and year of publication

For each variant, we reference at least one publication, and more if multiple published protocols have used that variant. In order to frame the appropriate historical context, we try to find the earliest publication of that variant, although this is not always successful. Publications are listed by the last name of the first author "et al." unless in the extremely rare situation that there are only one or two authors. We then list the year of publication as the year that the manuscript was e-published (n.b. this is somewhat different than the standard protocol for bibliographies). If there is a clearly stated protocol acronym or code we list that in parentheses after the year.

Level of evidence

Next, we make an assertion as to the level of evidence of the trial reporting the regimen. Is it a randomized study, or a phase II protocol? Is it a retrospective case series? This section is under active evolution to include links to comparator arms and efficacy; see R-CHOP in follicular lymphoma as one example. For much more information, go to the levels of evidence page.

Entry criteria

Most regimens currently on HemOnc.org do not specify the entry criteria. Beginning with the randomized controlled trials, we are beginning to add the "top-line" entry criteria, generally of the format:

This regimen was intended for patients with disease X meeting conditions Y, Z.

This information is taken directly from the manuscript and is not yet in a standardized format. At this point reporting the more detailed inclusion and exclusion criteria is out of scope for the HemOnc.org project. See the Multiple myeloma page for an example of what this new information will look like.

Antineoplastics

Next, we list the antineoplastic drugs in the same order as the regimen acronym, or alphabetically in the absence of an acronym. Each drug is listed in a particular format:

Generic_name (Brand_name) units per unit measure route frequency on day(s) x (to y)

  • Example #1: Doxorubicin (Adriamycin) 50 mg/m2 IV once on day 1
  • Example #2: Bendamustine 90 mg/m2 IV once per day on days 1 & 2
    • Note: the brand name is omitted for two reasons: 1) this drug is well-recognized by its generic name and 2) there are two brand-name formulations with differing instructions for use.
  • Example #3: Cyclophosphamide (Cytoxan) 100 mg/m2 PO once per day on days 1 to 14
  • Example #4: Doxorubicin (Adriamycin) 10 mg/m2/d IV continuous infusion on days 1 to 4 (total dose 40 mg/m2)

Generic_name (Brand_name) is always an active link to the drug page. When a primary reference provides details about infusion time, we include them (this is not very common).

When a primary reference provides details about infusion order, we also provide that information (this is even less common).

Supportive medications

Immediately after the antineoplastics, we provide information on supportive medications such as antihistamines, antiemetics, etc. as provided in the original reference. Some references provide specific drugs but omit doses or routes and we make note of this. Other references recommend a category of medications and we provide the link to one of our drug category pages, e.g. granulocyte growth factors. Supportive medication information is highly variable and sometimes not present in the original reference, in which case it is omitted.

Dose reductions

We occasionally include information on dose reductions, but this has not been a focus of the HemOnc.org project to date. Please consult the original reference if you suspect you are not treating a standard patient (e.g. age > 70 years old, reduced cardiac function, etc.)!

Treatment duration and multi-part regimens

As with the drug information, we try to maintain a very consistent style for the length and number of cycles. Here are some common examples:

  • 21-day cycle x 6 cycles
  • 21-day cycle x 6 cycles
  • 28-day cycle x 4 to 6 cycles
  • 8 week course
  • 28-day cycles
  • 28-day cycles until progression, intolerance, or patient request to discontinue

Note that the first four examples are of limited duration, whereas the last two are indefinite. Generally, disease progression, intolerance due to side effects, or a patient's request to stop therapy are always reasons to discontinue therapy. However, we only explicitly list these type of stopping criteria when a reference also states them explicitly.

If a reference reports on a multi-part regimen, we take one of two approaches. If the regimen is clearly of limited duration and meant to be given as a "package" we include all of the information in one place. Here are two examples:

In other situations, there are clear separations between the phases of treatment. For example, the AIDA 2000 regimen to treat acute promyelocytic leukemia has an induction phase, a consolidation phase, and a maintenance phase. These are all linked together but are kept separate on the regimen page. There are often criteria to move from one part to another part of a multiphase regimen like AIDA 2000, such as achieving a certain level of disease response. When these criteria are reported in the original publication, we include them as a note in italics.

References

Finally, we include all of the original references, in chronological order, that we have used to populate the regimen information. These are listed in PubMed style, and include links to the original article (which is usually not free to access) and the PubMed citation. If a contributor has reviewed the original article for accuracy of content, you will see contains verified protocol. If you see contains protocol this means that a contributor was able to review the paper, but it lacked critical details such as dosing, total number of cycles, etc. If neither of these statements are present, please be aware that the information present is based on an abstract and may not be wholly accurate or complete. Of course, our standard disclaimer always applies!

When a trial has updated results, we nest the reference(s) underneath the original reference. Example:

  1. Rummel MJ, Niederle N, Maschmeyer G, Banat GA, von Grünhagen U, Losem C, Kofahl-Krause D, Heil G, Welslau M, Balser C, Kaiser U, Weidmann E, Dürk H, Ballo H, Stauch M, Roller F, Barth J, Hoelzer D, Hinke A, Brugger W; on behalf of the Study group indolent Lymphomas (StiL). Bendamustine plus rituximab versus CHOP plus rituximab as first-line treatment for patients with indolent and mantle-cell lymphomas: an open-label, multicentre, randomised, phase 3 non-inferiority trial. Lancet. 2013 Apr 6;381(9873):1203-10. Epub 2013 Feb 20. Erratum in: Lancet. 2013 Apr 6;381(9873):1184. link to original article contains verified protocol PubMed
    1. Update: Abstract: Mathias J. Rummel, MD, Georg Maschmeyer, MD, Arnold Ganser, Andrea Heider, PhD, Ulrich von Grünhagen, MD, PhD5, Christoph Losem, Gerhard Heil, MD, Manfred Welslau, Christina Balser, MD, Ulrich Kaiser, MD, Eckhart Weidmann, Heinz Dürk, MD, Hans Peter Böck, Martina Beate Stauch, MD, Jürgen Barth, Wolfgang Blau, MD, Alexander Burchardt, MD, Frank Kauff, PhD, Axel Hinke, PhD and Wolfram Brugger, MD. Bendamustine Plus Rituximab (B-R) Versus CHOP Plus Rituximab (CHOP-R) As First-Line Treatment in Patients with Indolent and Mantle Cell Lymphomas (MCL) – 7 Year Updated Results from the StiL NHL1 Study. ASH Annual Meeting 2014, Abstract 4407 link to abstract

We also occasionally add regimens based on abstract presentations, before a manuscript has been published. In these cases we clearly label the reference with Abstract:. Additionally, once (if) a manuscript is published we replace the abstract reference with the published reference. For example, the StiL NHL1 Study referenced above was first presented as an abstract in 2012:

  1. Abstract: Mathias J. Rummel, Norbert Niederle, Georg Maschmeyer, Andre G. Banat, Ulrich von Gruenhagen, Christoph Losem, Dorothea Kofahl-Krause, Gerhard Heil, Manfred Welslau, Christina Balser, Ulrich Kaiser, Eckhart Weidmann, Heinz A. Duerk, Harald Ballo, Martina Stauch, Juergen Barth, Axel Hinke, Wolfram Brugger, Study Group Indolent Lymphomas (StiL). Bendamustine plus rituximab (B-R) versus CHOP plus rituximab (CHOP-R) as first-line treatment in patients with indolent and mantle cell lymphomas (MCL): Updated results from the StiL NHL1 study. 2012 ASCO Annual Meeting abstract 3. link to abstract ASCO Post article ASCO plenary session video

If you are curious, we do preserve these abstract references as hidden fields; you will need editing privileges in order to view these.

Example order sets

Many individual practitioners and organizations do not follow published regimens to the letter. This may be because the published regimen is under-specified, especially with respect to supportive medications, sequencing, and infusion times; or, it may be because local patterns influence treatment choices (again, this is probably most applicable to supportive medications such as antiemetics). For this reason, we have created a number of example order sets, which can be accessed directly or searched for. For example, the mFOLFOX 6 regimen on the colon cancer page has a link to the example orders for mFOLFOX 6 in colon cancer. There are many fewer example order sets than chemotherapy regimens currently, so this is another area where your contributions would be most appreciated!

Drug index

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Beyond the main page and the chemotherapy regimen pages, this is probably where you'll want to go next. This page is pretty self-explanatory but there are a few nuances you may be interested in:

Alphabetical list of drugs

Here, we list drugs alphabetically by their generic name. For all approved drugs, we also include their brand name (if there is more than one brand name we try to choose the most recognizable). Drugs that are under study are labeled in clinical trials. If a drug has been approved in the current or previous calendar year, we list the details right next to the drug, e.g. FDA Approved 7/3/2014. You will probably notice quickly that there are a fair number of red links, which means that the linked page does not yet exist. Help make it happen by contributing!

Drugs by category

Here, we list drugs under a number of different categories. A drug can, of course, be listed under many different categories. For instance, most drugs are categorized by at a minimum their mechanism of action, the diseases for which they are used, and the year that they were approved. See Individual drug pages for more details.

Interesting and helpful links

As the name says, these links are placed here because they have directly relevance to drugs, e.g. the ASCO-ONS Standards for Safe Chemotherapy Administration

Individual drug pages

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As with the chemotherapy regimens, we try to use a predictable style across all individual drug pages. They are sectioned as follows:

General information

Here, we provide a description of the mechanism of action (if known), as well as the route(s) and any other important information, such as links to REMS programs. For conciseness and simplicity, HemOnc.org currently will focus on treatment regimens and not list information such as: renal/hepatic dose adjustments, metabolism (including CYP450), excretion, monitoring parameters (although this will be considered for checklists), or manufacturer. Instead, for the most current information, please refer to your preferred pharmacopeias such as Micromedex, Lexicomp, UpToDate (courtesy of Lexicomp), or the prescribing information. For most antineoplastics, we provide links to the package insert provided by the manufacturer, as well as a locally-hosted backup.

Diseases for which it is used

These are the specific cancer histologies for which some degree of efficacy has been demonstrated. This is NOT the same as saying that the drug is FDA-approved or even on an approved compendium listing; we are merely stating that there is some evidence to support efficacy. These links will take you to the respective Chemotherapy regimen page.

Patient drug information

As indicated, these links are meant to be useful for patients.

History of changes in FDA indication

Here we try to include, at a minimum, the initial date of FDA approval for a cancer-related indication. When the information is available from the FDA, we also include the specific language regarding the approval; this is quite hard to locate for some of the older drugs. We also do our best to update this list with new indications.

Also known as

Here we provide synonyms, which can be only a few or sometimes hundreds, as is the case for dexamethasone. We try to include the original coded designators here, since these are often used colloquially for many years after a drug is approved (e.g. "CPT-11" is still in the vernacular). If you notice that a coded name or other synonym seems to be missing, this is an easy and impactful area for you to contribute to.

References

Self-explanatory

Categories

At the bottom of each drug page, there is a list of any number of categories that the drug has been assigned to. By clicking on one of these categories, you can easily move from a drug page to a list of similar drugs in the class, or a list of drugs approved in the same year, etc. These categories also feed into the drugs by category on the main drug index page.

Search box

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There is a search box in the upper right hand corner of every page. If you are looking for something on the site, a good way to start is by typing in some search terms and either pressing enter on your keyboard or clicking the magnifying glass. If there is a page which exactly matches what you've typed in, that will automatically show up, and you can go directly to that page by clicking on the name.

Left sidebar

No matter what page you're on, you'll always see links on the left part of the page which will take you to some of the most useful pages on the site. Clicking the HemOnc.org logo will take you to the front page, which has links to all of our chemotherapy regimen pages.

References

This menu contains many potentially useful resources. We have carved out individual pages for some of the most frequently used, such as billing codes, antiemetic support, and performance status. Our vesicant and irritant chemotherapy page is one of our most heavily visited, and might very well be the way you found your way to the site.

Beyond these pages, we have an external links page with many, many more links. If you find your organization represented here, please consider linking us back!

Stay in touch

If you enjoy using HemOnc.org, we would really appreciate it if you could spread awareness through social media such as Facebook or Twitter. You are also welcome to join our mailing list. HemOnc.org is completely not-for-profit and does not have an operating budget; we rely on the voluntary contributions of users and word-of-mouth to spread awareness. Thank you for spreading the word!

Tools

This information is not really too useful for users of the site but is certainly relevant to contributors. So, if you've actually read all the way to the end of this tutorial, we strongly urge you to sign up and contribute. Thanks for reading!