The Agency for Health Care Policy and Research established a forum for quality and effectiveness in health care under which practice guidelines were to be evaluated. The groups involved in this forum turned to the Institute of Medicine to evaluate the entire issue of such guidelines. The Institute of Medicine identified considerable conflicts and differences in terminology and defined four different but related definitions[1,2]:
- Practice guidelines are systematically developed statements to assist practitioners in making decisions about appropriate health care for patients in specific clinical circumstances.
- Medical review criteria are systematically developed statements that can be used to assess the appropriateness of specific health-care decisions, services, and outcomes.
- Standards of quality are authoritative statements of minimal levels of acceptable performance or results, excellent levels of performance or results, or the range of acceptable performance or results.
- Performance measures are methods to estimate or monitor the extent to which the actions of a health-care practitioner conform to practice guidelines.
Thousands of practice guidelines/practice parameters have been published by various professional organizations. The American Medical Association,[3] American College of Physicians,[4,5] and others[6-8] have written extensively about methodologic, quality, and cost considerations in relation to such guidelines. In the early 1990s, the Society of Surgical Oncology participated in the development of extensive evidence-based standards of care for breast conservation treatment of primary breast cancer patients.[9]
More recently, the Society undertook a more ambitious initiative aimed at developing surgical practice guidelines directed toward the evaluation and initial management of patients with signs and symptoms cancer. These guidelines encompass the major cancer sites.
Scope and Format of the Guidelines
The Society of Surgical Oncology practice guidelines were based on detailed review by nationally recognized experts in their respective fields. Each guideline represents a consensus of multiple members of the Society of Surgical Oncology who are well known for their expertise. The authors have stressed the symptoms and signs of primary cancer without discussing screening programs. The guidelines also discuss the timely evaluation of the symptomatic patient, appropriate preoperative evaluation for extent of disease, and the role of the surgeon in the diagnosis and treatment of cancer.
Separate sections on adjuvant therapy, follow-up programs, or management of recurrent cancer have been intentionally omitted. For many sites, perioperative adjuvant combined-modality therapy has been shown to improve outcomes. Where appropriate, such therapy is discussed under surgical management.
The guidelines are presented in minimal outline form as a delineation of therapeutic options. It is not the intent of these guidelines to define in detail all of the alternatives, risks, and outcomes for surgical or combined-modality therapy of the cancer patient. For most sites, the generally acceptable therapeutic options are defined.
Following each guideline is a brief narrative highlighting and expanding on selected sections of the guideline document, with a few relevant references. The current staging system for the site and approximate 5-year survival data are also included.
As stressed by the Institute of Medicine, some degree of diversity is warranted by differences in the interpretation of scientific evidence, differences in individual patient characteristics, and physicians' preferences, as well as local variation in medical resources. However, diversity in practice is unacceptable when it originates from poor skills, poor management of the delivery system, ignorance, or deliberate disregard of well-documented, preferable practices.
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
