FORT LAUDERDALE, Fla--Unlike the piecemeal development of clinical
practice guidelines in the United States--by individual institutions,
networks, or managed care plans--in Canada, guidelines development
is a provincial effort, with the resulting product applying to
all oncologists in the province, Mark Levine, MD, said at the
first annual conference of the National Comprehensive Cancer Network
In the province of Ontario, with a population of 10 million, the
process has been ongoing for 4 years, including an initial pilot
program, said Dr. Levine, director of the Comprehensive Cancer
Center, Hamilton, Ontario, and a member of the steering committee
of the Ontario Practice Guidelines Initiative.
An 8-member coordinating committee oversees the entire process,
while disease site groups do the work of writing specific guidelines.
The cancer site groups each include, among others, a medical oncologist,
radiation oncologist, surgeon, nurse, and radiation therapist,
and they receive assistance from a methodologist and librarian
to help with literature searches. Dr. Levine stressed that the
disease site groups must include practicing physicians. "If
it doesn't come up from the grass roots, then it's imposed from
on top, and it isn't going to work."
A framework, known as the practice guidelines cycle, was developed
to aid the cancer site groups in writing the guidelines by outlining
specific steps to follow.
The group first selects and frames the clinical problem. Topics
may be prioritized by different means, Dr. Levine said, including
prevalence of a condition, burden of illness, potential for significant
health benefit, relevance to local practice patterns, degree of
variation in practices, and availability of high-quality evidence.
The site group next selects the main outcomes, reviews the literature,
and, after consensus-building discussions, generates evidence-based
recommendations, using levels of evidence to indicate the panel's
confidence in specific recommendations. Dr. Levine said that the
panel must "write down its logic and make explicit its rationale
A particular problem faced by oncol-ogy guideline site groups
is that standard practices are often not supported by good level
1 or 2 evidence. To get around this, the groups recommend changes
in conventional practices, when the practice is unsupported by
randomized trials, only when there is level 1 or 2 evidence to
support the change.