Guideline Update for 4/2/2025

National Cancer Comprehensive Network (NCCN)

The NCCN guidelines can be found at www.nccn.org.

Anal Carcinoma Version 3.2025

The latest update for anal carcinoma includes a new footnoted recommendation to consider DPYD genetic variant testing prior to initiating fluoropyrimidine therapy. While no specific assay is endorsed, and data remain limited regarding dose modification for many variants, shared decision-making regarding DPYD testing is advised to mitigate fluoropyrimidine-associated toxicity.

Bladder Cancer Version 1.2025

The 2025 NCCN bladder cancer guideline updates include expanded adjuvant immunotherapy options, extensive changes to the principles of systemic therapy, and a new separate section concerning the principles of alternative risk classifiers and biomarkers. Notably, adjuvant pembrolizumab is now recommended as an option to nivolumab for patients with residual disease post-neoadjuvant cisplatin-based chemotherapy. The instillation therapy section has been reorganized, and novel agents such as nadofaragene firadenovec and nogapendekin alfa inbakicept are highlighted for select BCG-unresponsive NMIBC. Enhanced guidance is also provided for subtype-specific risk stratification, use of bladder-sparing approaches, and advanced imaging protocols across disease stages. Furthermore, throughout the guidelines the terminology of “Tis” has been replaced with “CIS”.

Colon Cancer Version 2.2025

The updated guidelines include consideration of PIK3CA mutation testing in stage II–III resectable disease, with a new recommendation to add daily aspirin (100–162 mg) for three years in patients with PIK3CA-mutated tumors. Similar to the new recommendations in the guidelines for anal carcinoma, DPYD testing may now be considered prior to fluoropyrimidine therapy, and shared decision-making is emphasized given potential fluoropyrimidine toxicity risks.

Esophageal and Esophagogastric Junction Cancers Version 2.2025

Even though Version 1.2025 was published about a month ago, the NCCN has issued an update to clarify the category 1 recommendation of fluoropyrimidine, oxaliplatin (or cisplatin), and nivolumab for PD-L1 CPS ≥1.

Neuroendocrine and Adrenal Tumors Version 1.2025

The 2025 NCCN update includes extensive revisions across neuroendocrine and adrenal tumor subtypes. Notable additions include routine consideration of tumor molecular profiling for unresectable/metastatic cases, expanded use of PRRT (lutetium Lu 177 dotatate) as first-line therapy in SSTR-positive, Ki-67 ≥10% disease, and inclusion of cabozantinib, selpercatinib, and osilodrostat for specific indications. Surveillance strategies have been refined, and the role of short-acting octreotide has been emphasized for symptom control. Updated imaging recommendations clarify use of SSTR- and FDG-PET tracers.

Primary Cutaneous Lymphomas Version 2.2025

Discussion sections were updated to reflect algorithm changes in the management of primary cutaneous B-cell lymphomas, mycosis fungoides and Sézary syndrome, and primary cutaneous CD30+ T-cell lymphoproliferative disorders.

Rectal Cancer Version 2.2025

The latest NCCN update for rectal cancer mirrors recent changes to the colon cancer guidelines, including consideration of PIK3CA mutation testing in stage II–III resectable disease, with a recommendation to add daily aspirin (100–162 mg) for three years in patients with PIK3CA-mutated tumors. As with the updated guidance for anal and colon cancers, DPYD testing may be considered prior to fluoropyrimidine therapy, with an emphasis on shared decision-making due to potential toxicity risks.

Small Bowel Adenocarcinoma Version 3.2025

Much like the other NCCN guidelines concerning colon, rectal, and anal cancers, the NCCN now notes that DYPD testing may be considered prior to fluoropyrimidine therapy, with an emphasis on shared decision-making due to potential toxicity risks.

Thyroid Carcinoma Version 1.2025

The latest NCCN guidelines include extensive revisions across all histologic subtypes. Key updates involve refined criteria for radioactive iodine (RAI) use based on risk stratification, changes concerning molecular diagnostics (especially BRAF V600E and RET alterations), and clarified recommendations for active surveillance in low-risk disease. Recommendations address the use of systemic therapies—including kinase inhibitors—for RAI-refractory and progressive disease, along with updated protocols for imaging, postoperative management, and monitoring. Extensive modifications were made to the algorithm for recurrent or persistent locoregional disease for medullary carcinoma.

Diabetes Canada

The 2025 Diabetes Canada guideline for glycemic management in type 1 diabetes emphasizes individualized, person- and family-centered care across the lifespan. Key updates include recommending automated insulin delivery (AID) systems as first-line therapy for all individuals where feasible, with continuous glucose monitoring preferred even when AID is not used. New pediatric A1C targets align with adult goals (<7.0%) across all ages. Ultrarapid- and ultralong-acting insulin analogues are endorsed to improve time in range and reduce hypoglycemia. Adjunctive therapies (metformin, GLP-1RAs, SGLT2 inhibitors) may be considered in adults using a shared decision-making approach, with monitoring for risks such as gastrointestinal effects and euglycemic diabetic ketoacidosis (DKA). The guideline also provides updated pediatric-specific recommendations for treating hypoglycemia and endorses subcutaneous insulin for selected cases of non-severe DKA.

ACC/AHA/ACEP/NAEMSP/SCAI

Recently, we published the update regarding the new ACC/AHA/ACEP/NAEMSP/SCAI joint guidelines concerning acute coronary syndromes. The authors have published corrections to these guidelines.

• “Liver function test abnormalities” replaces “hyperuricemia” as potential adverse effect of ezetimibe (in Table 11).
• The name of one of the section members has been updated to Noreen Nazir, MD, FACC.

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