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Guidelines for cancer care: slipping the net

By Will Davies, ecancer Medical Reporter

Why aren't doctors using an evidenced based approach to treat cancer?

The nature of oncology is, by no small twist of irony, one of growth and evolution, just as much as the diseases we aim to treat.

Keeping up to date with the latest in clinical advances is a challenge, and one that led to the founding of ecancer some 10 years ago.

However, these advances are often piecemeal; multiple phases of clinical trials of single agents and their ensuing combinations mean the field will not change over-night.

This is, of course, for the best. The scientific method is one of following evidence, not intuition, and not jeopardising patients’ lives with immature data or the guidance of vested interests.

The steps in a single patients treatment, finding the regimen that can offer the best chance at the longest life with the lowest side effects, are earned through the lives and legacies of thousands of test participants, whose own experience may ultimately inform the design of the standard of care for those who follow.

And so to guidelines for care, a core plan of action through which any patient might be treated.
These guidelines, too, can change, to reflect the summation of all those finger-hold gains above, and but they should be the best bulwark against disease progression for whichever disease a patient has.

It should go without saying, then, that patients whose therapy follows those guidelines have better outcomes.

And yet it has to be said.

Not just in the treatment of cancer, but across multiple indications, it appears that the guidelines of treatments have to prove their value, which raises the question: why are more doctors not following an evidence-based approach?

As mentioned above, immature data and the invisible hand of economic gain are the two immediate reasons for going off-course.

In the first case, induction of patients into clinical trials can make a different course of treatment available, should the physician believe it to be the best course of action, and this comes with ethical evaluation, patient discussion, and a robust process to protect those involved from undue harm.

In the other, there are already doubts cast on those who compile guidelines without declaring financial conflicts of interest

This was the discussed in some length by Dr Bishal Gyawali in one of his blogs for ecancer.

In a just world, this kind of influence would never endanger patients by steering them from the best course of action, but sadly this is not the reality for many.

Regardless of financial influence for physicians, the high cost of the latest drugs rarely reflect a proportional clinical benefit, with surgery and radiotherapy having greater impact at lower cost.
Of course, best practice varies depending on resource availability, but they are guidelines in their own specific setting.

Those made available through the American Society of Clinical Oncology or the European Society of Medical Oncology are intended to address regional availability in their own turn.

So, why else are doctors not following evidence based guidelines?

Systematic inconsistency in guidelines can only lead to their inconsistent application, and seems an essential starting point.

The authors of the breast cancer study referenced above offer that more local guidelines and more rapidly distributed updates online would offer more contextualised, and thus more likely, steerage for clinicians.

They also encourage a more open dialogue between physicians and their patients, identifying what guidelines advise, and justifying any derivation. Others suggest a whole new management schema for keeping up to date with rapid advances.

Hopefully, that discussion can start here.

Through comments below, let us know your experience of working within and outside of clinical guidelines; what changes would you consider to maintain optimal treatment for the most patients?

 

 

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Henning Tietgenstein / 13.12.2016

I like this article. In that context, I wanted to mention this publication: The impact of cancer prevention guideline adherence on overall mortality in a high-risk cohort of women from the New York site of the Breast Cancer Family Registry. Breast Cancer Res Treat. 2015; 149: 537–546.
Clearly, it pays to adhere to these guidelines.

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