BUFFALO, NYEvidence-based practice guidelines are needed to
improve the quality of cancer care, several representatives from the
professional cancer societies told the Presidents Cancer Panel
at a meeting hosted by Roswell Park Cancer Institute . But expert
physicians also play a critical role in the creation of practice
guidelines, particularly in situations where evidence is lacking or
In the late 1980s, physicians missed significant opportunities
to direct practice guidelines, said William T. McGivney, PhD,
chief executive officer of the National Comprehensive Cancer Network
(NCCN). Our process seeks to restore physician authority in
determining appropriate practice guidelines. The NCCN
guidelines are based on scientific evidence integrated with expert
medical opinion. Medical autonomy must be returned to
practicing oncologists, he said.
In just 3 years, the NCCN has completed three volumes of guidelines
that cover 90% of all cancers. NCCN guidelines are current, specific
in their recommendations, and updated continuously by expert panels
that include more than 500 physicians. The fourth volume, to be
unveiled next spring, will increase the NCCN guideline coverage to
about 95% of all cancers. [See page 3 for an interview with Dr.
McGivney and Dr. Rodger Winn on the upcoming NCCN meeting.]
We believe that physician experts must control the guideline
process, especially where a consensus approach is needed due to
controversial and/or insufficient evidence, Dr. McGivney said.
It is critical for patient care that these guidelines are driven by
the medical profession, he added, because we need our member
institutions to follow them to make cancer care consistent,
effective, and cost effective. The experts also play a continuing
role in the re-evaluation process when new evidence is brought to light.
While the NCCN is working to quickly create basic guidelines for all
cancers, as well as convert them into patient guides, the American
Society of Clinical Oncology (ASCO) has proceeded at a slower pace.
ASCO uses a longer process for creating guidelines that relies on a
stricter evidence-based methodology.
While we have made important progress, there are also many
pitfalls in guideline development and implementation, said Mark
Somerfield, PhD, director of ASCOs Health Services Research
Department. Our challenge today is to determine how effective
guidelines actually are in improving the quality of cancer care in
this country, he added.
ASCO currently has issued four evidence-based practice
guidelineson breast cancer surveillance, treatment of
unresectable non-small-cell lung cancer (NSCLC), use of tumor markers
in breast and colorectal cancer, and use of hematopoietic colony-stimulating
factors (CSFs). Ten additional guidelines are in development, and
the Society is also modifying the breast cancer surveillance and
advanced NSCLC treatment guidelines for a lay audience.
The ASCO review process uses several criteria to select a guideline
topic: the cost of a procedure, importance of the subject, perception
of high practice variation, and availability of evidence. When a
guideline idea passes that review, a committee is formed to create
Use of any ASCO guideline is optional among its members, and when the
ASCO guideline for CSFs was first released, physicians were somewhat
slow to apply it to their practices, Dr. Somerfield said. It was not
until its use was emphasized to physicians that significant cost
savings were realized with use of the guideline.
It has been shown that there was a decrease in overall CSF cost
when physicians were encouraged to implement the ASCO guideline
through a mechanism of accountability, Dr. Somerfield said.
We are now looking into the reasons for the slow acceptance of
the CSF guideline by physicians.
Currently, ASCO is asking its members and other payers and providers
to evaluate its guidelines in terms of quality and satisfaction, and
to assess whether the guidelines are leading to changes in physician
practices. Our ultimate goal is to learn if these guidelines
impact the quality of patient care, Dr. Somerfield commented.
To ensure that guidelines promote the highest standard of care for
cancer patients, academic centers must play a role in their
development, dissemination, and implementation, said Rodger J. Winn,
MD, chief of the Section of Community Oncology in the Department of
Clinical Investigations, M.D. Anderson Cancer Center, and
representative for the American Association of Cancer Institutes
(AACI). I believe that our guidelines must promote the gold
standard of care based upon the scientific evidence, said Dr.
Winn, who is also chair of the guidelines committee for the NCCN.
Dr. Winn believes that the most critical role for academic centers is
to prevent bias in practice guidelines. Experts from cancer
institutes offer multiple treatment approaches, including regional
considerations, that must be assessed before a national guideline can
be created, he said.
Academic centers also can examine existing guidelines and demonstrate
that they are reproducible; that is, that a second group of experts
agrees with the recommendations of a previously published practice guideline.
For example, the AACI looked at the same data that the NCCN and ASCO
used in developing their guidelines for the treatment of
non-small-cell lung cancer, and found that both groups used the same
endpoints and came up with very similar treatment recommendations.
We can show that these guidelines meet the criteria of quality
care, but the academic centers should not stop there, Dr. Winn
said. We cannot forget the need for clinical trials to further
the scientific evidence. Academic centers play a pivotal role in
coordinating care among community physicians, hospitals, and managed
care companies, but their focus must always be on the addition of