Guidelines Help Ensure Quality of Breast Cancer Care

CHICAGO—The decisions doctors make regarding breast cancer care vary widely, as do the guidelines that these doctors may reference when making treatment decisions. Speaking at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University’s annual Health Policy Symposium, Stephen B. Edge, MD, of Roswell Park Cancer Institute and the State University of New York-Buffalo, discussed several breast cancer practice guidelines and the means by which they can become most useful.

Dr. Edge said that variations in treatment practice do not necessarily translate into variations in quality of care. Guidelines can facilitate evaluation of the quality of care by comparing actual treatment of a specific patient with a set practice guideline. This enables providers to prove to insurers the effectiveness of their treatments and provides useful data for quality assessment of individual physicians and medical facilities.

For these guidelines to be of most use, Dr. Edge argued that they must be a part of a program that improves quality, cost-effectiveness, and outcomes. He reviewed five comprehensive guideline program efforts, each focusing on different aspects of the disease and varying in scope.

• Ontario Cancer Treatment Practice Guidelines Initiative, one of the first comprehensive guidelines developed, addresses several specific clinical situations.

• Revlon/UCLA Breast Cancer Guidelines provide standards for diagnostic evaluation of suspicious findings, treatment of primary and recurrent disease, and adjuvant systemic therapy.

• Society of Surgical Oncology Guidelines provide standard approaches to the evaluation of symptoms, abnormalities, and surgical treatment of breast cancer. Association of Community Cancer Centers (ACCC) guidelines offer standards for initial staging, management of local disease, and adjuvant systemic therapy of early-stage disease.

• National Comprehensive Cancer Network (NCCN) guidelines address all aspects of treatment after diagnosis, including stage workup, local therapy, adjuvant systemic therapy, follow-up care, and treatment for recurrent disease.

One of the main challenges of practice guidelines is how to appropriately revise and incorporate innovations in the standard of care. Such revision is essential to keep the guidelines current. The guidelines reviewed above employ a variety of methods for revision and re-evaluation.

In addition to regular updating, there must be an ongoing evaluation of a guideline’s utility for its targeted audience. Efforts aiming at addressing the usefulness of guidelines include retrospective comparisons of actual practice to published standards, examination of the effect of published guidelines on actual practice by reviewing data before and after the time the guidelines were published, and the measurement of practice standards and comparison to an individual physician’s practice.

Practice Outcomes

Dr. Edge argued that the ultimate goal of such studies will be to assess whether the use of guidelines improves patient outcomes. Unfortunately, due to the complexity of breast cancer care, the use of the guidelines mentioned above has not yet been shown to improve outcome.

There are several obstacles to obtaining appropriate data on the effect of guideline use on outcomes in breast cancer care. First, most care takes place at outpatient facilities not affiliated with each other, making data gathering very complex. Second, outcomes data need to be collected over a long period of time. These data need to include not only survival and recurrence outcomes but also quality-of-life outcomes such as breast preservation, cosmesis, treatment toxicity, and psychological state.

Guidelines from three of the groups mentioned (Ontario, Revlon/UCLA, and NCCN) include the evaluation of the utility of their guidelines within an overall quality management program. The NCCN has been able to incorporate information gathered while studying the practical utility of its guidelines into its revised guidelines.

In conclusion, to attain comprehensive quality improvement of guidelines and thereby improve their efficacy, appropriate methods for continual updating, quality monitoring, and utility assessments are necessary.

In addition, Dr. Edge suggested that open communication between practitioners in different communities and the panels instituting guidelines needs to be established prior to guideline publication. This process would allow for the inclusion of acceptable deviations from standard practice in the guidelines.

Finally, implementation of better methods to facilitate data gathering for study purposes and more efficient dissemination of guideline information would also assist guideline quality improvement efforts.

Bibliography

Edge SB: Breast Cancer Practice Guidelines: Evaluation and Quality Improvement. NCCN Proc. ONCOLOGY 11(11A):151-154, 1997.