The NCCN Clinical Practice Guidelines on Liver Cancer: Guidelines for All Settings?

Liver cancer occurs relatively infrequently in the United States. As Arciero and Sigurdson (in this issue) point out, only 18,000 cases are expected this year. The important fact to remember, though, is that, worldwide, hepatocellular cancer ranks as one of the most devastating tumors. In China, for instance, with its estimated 130 million cases of chronic heptatis B infection, more than 300,000 deaths occur a year from liver cancer. The reasons for this high prevalence worldwide are multiple, including hepatitis B and C virus infection, aflatoxins, and chemical exposures, so improvement in preventative rather than therapeutic measures may ultimately be the step that eradicates the morbidity and mortality from the disease. This month's article by Kulik explores the possible role of interferon-based therapy in halting the progression of hepatitis C disease to its malignant phase.Meanwhile, the asymmetric international distribution of liver cancers raises an interesting problem for guideline users—are the NCCN guidelines usable as they are promulgated or can they be modified to accommodate local practices and cultural preferences? This question was brought home vividly at an NCCN conference in India. The attendees pointed out that the NCCN cervix screening guideline recommendations based on PAP test findings are irrelevant in many local sites, because annual PAP testing would far exceed the economic resources of many villages. In addition, the cervix treatment guidelines were believed to be unnecessarily nuanced for early stage disease, which was not relevant there, because only stage 3 and 4 disease was seen in these settings...

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Rodger J. Winn is the Editor-in-Chief of JNCCN. He is Clinical Consultant at the National Quality Forum, and his past positions include Associate Professor of Clinical Medicine at The University of Texas M. D. Anderson Cancer Center. Dr. Winn received his medical degree from Jefferson Medical College of Philadelphia. His postgraduate training includes an internship and residency at Jefferson Medical College, and he also completed a medical oncology fellowship at Memorial Sloan-Kettering Cancer Center in New York. He is board certified in internal medicine and holds subspecialty certification in oncology.

References

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FerversBBurgersJSHaughMC. Adaptation of clinical guidelines: literature review and proposition for a framework and procedure. Int J Qual Health Care2006;18:167176.

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