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 (NCCN).
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 for decisions."
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.