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Rodger J. Winn

The Mission Statement of every institution, hospital, and medical group declares the professional commitment to provide care that is “the most up-to-date” and “state-of-the-art.” For the most part, this goal is met, but it still must be placed in context. For the year 2002, a search of PubMed under breast cancer, human, English yields 5,496 entries. The daunting task for the oncology team becomes, then, the challenge of reading 15 articles a day, each and every day, and still finding time to keep up with the nonbreast cancer literature. One solution, of course, is the distillation of current knowledge into a clinical practice guideline by a broad panel of experts committed to keeping abreast of the plethora of new advances. Considering the enormous breadth of new information, it comes as no surprise that this JNCCN presents three separate breast cancer-oriented guidelines: treatment, screening and diagnosis, and risk reduction. The second major issue in using guidelines to maintain currency is the schedule of updates. A study of the AHCPR national guidelines showed that guidelines began to loose considerable validity after three years. 1 A worrisome finding is that despite the existence of new data, the old guidelines remained in use. For this reason, the NCCN annual review process assures us that the recommendations reflect information of the latest vintage. Each guideline recommendation is built on a body of data and analysis. Many times, the pithy, straightforward recommendation reflects the amassing of a body of data, major debate on its significance, and a...
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Rodger J. Winn

We all take pride in our designated profession—oncology, the study of tumors. In its infancy as a specialty, oncology focused on the biology of tumors and the means to alter the relentless progression of these uninhibited cells. Had the specialty restricted its purview to only the use of specific antitumor interventions, we would have designated ourselves as cancer surgeons, radiotherapists, and chemotherapists. But we do not: we are surgical oncologists, radiation oncologists, and medical oncologists. Although it is perhaps literally the study of tumors, in reality oncology is the study of the care of the cancer patient, care viewed in it all its dimensions. From this overarching perspective, supportive care and symptom management are seen as being as much a part of the oncologist's expertise as surgical techniques or radiation and chemotherapy dosing. What has also emerged is a group of clinical scientists who have made their research goals the systematic study of symptoms—their pathogenesis, measurement, and amelioration. In some areas of supportive care, the needs of the cancer patient are unique. The science and pharmacology of managing chemotherapy-induced nausea and vomiting is a prime example of a symptom complex primarily addressed in the cancer world. In others areas, the symptom was traditionally studied and treated by other disciplines, and only recently has oncology focused on the ramifications of management within the context of antitumor therapy. In some instances, this must involve the acquisition of new skills and an expansion of clinical expertise. A good example is depression, which is...
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Rodger J. Winn

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Rodger J. Winn

One of the hallmarks of the oncology scientific community has been a general reluctance to sensationalize advances. Although the news media tends to blare forth with the breakthrough of the week, or even du jour, investigators reporting results usually cloak them with caution and almost always point to the need for further studies. This is not to say, however, that the oncology community is shrouded in a pall of pessimism. The willingness to treat these devastating diseases and provide compassionate support and hope, grounded in realistic expectations, has earned the specialty the (sometimes begrudging) admiration of non-oncology practitioners. And for many years, one of the precepts that enabled oncologists to provide honest succor to patients was the well-grounded belief that progress was being made, if slowly, in small but well-defined increments. Thus, the breathtaking change in pace we see now in understanding the underlying mechanisms of carcinogenesis and introducing innovative approaches to therapy based on this understanding that now confronts (blesses) the oncology world evokes almost a sense of disbelief. I would guess that, for the past decade, no clinician has left a major meeting thinking, “nothing really new is happening.” Multiple myeloma, highlighted in this issue, may well serve as the cover disease for this remarkable change of pace. When first published, the NCCN Multiple Myeloma Clinical Practice Guidelines rested squarely on standard alkylating agents and corticosteroid treatment or well-tested regimens such as VAD that had been the mainstay of treatment for more than 30 years. Since this initial...
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Rodger J. Winn

One of the major premises supporting the development of clinical practice guidelines is that they promote increased consistency in health care practices.1 A decrease in random variation in this care, we reason, will, in turn, lead to better patient outcomes, increased patient confidence and satisfaction, and more efficient use of resources.2 Is this premise correct? In a review of 59 non-cancer guidelines, Grimshaw and Russell3 reported that 55 led to a change in medical practice, and 9 of 11 showed an improvement in patient outcomes. In a review of oncology-related guideline studies, Smith and Hillner4 noted some evidence of the effect of guidelines and critical care pathways on decreasing costs, but pointed out the need for more data about other outcomes. In attempting to answer the question of whether oncology guidelines “work,” we can assess a multiplicity of end-points: • Have oncologists accepted the basic premise that guidelines are useful? • Are oncologists aware that guidelines exist, and do they access them? • Do the practice patterns of oncologists conform to standard guidelines recommendations? • Does the implementation of guidelines change oncology practice behavior? • Does the use of guidelines lead to better patient outcomes? Oncologist Acceptance of the Concept In line with other specialties,5 modern oncologists seem to acknowledge the utility of clinical practice guidelines. In a survey of Canadian oncologists,6 86% agreed with a statement that guidelines were a useful educational tool, and 83% believed they were a good source of advice, whereas only 4% of those surveyed...
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Rodger J. Winn

It is axiomatic that state-of-the art antineoplastic therapy calls for a multi-pronged strategy with an emphasis on integrating complementary and, hopefully, synergistic modalities. With the advent of more-precise molecular and genetic typing and the identification of responsive and resistant subgroups, this therapy is also becoming more customized; one size no longer fits all. The net result of this heterogeneous approach is a greater burden on the oncologist caregiver. The field has progressed far beyond the cookbook stage, when once we knew the tumor type, the treatment choice flowed somewhat automatically. What is not so readily apparent, however, is that this complexity of management decisions also extends to the use of supportive care agents. In the not too distant past, the practicing oncologist had only a limited repertoire of interventions to manage such incapacitating and even limiting events as intractable chemotherapy-induced vomiting, but today a much broader array of interventions is available. This array of treatment options, in turn, has led to the increasing need to characterize the clinical aspects of the syndromes, to apply individualized treatments. The science of emesis continues to evolve. Introduction of the 5-HT3 receptor inhibitors were a significant advance in managing the acute vomiting that follows closely after the administration of highly emetogenic agents, but control was certainly not complete. Two articles in this issue address the further refinements in the management of post-chemotherapy vomiting. Stoutenberg and Raftopoulos review the physiology and clinical effectiveness of a new class of antiemetic agents, the NK1 receptor antagonists, as...
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Rodger J. Winn

One of the cancer-related Healthy People 2010 goals is to decrease deaths from cancer of the cervix in the U.S. from 3/100,000 to 2/100,000. The basis for this goal is the tremendous impact of the Papanicolaou (Pap) test in reducing mortality from this once common and devastating cancer. Over the past 50 years, U.S. death rates have dropped by 75%, and the target is certainly possible if screening and appropriate follow-up can be extended to all women. Given the remarkable effectiveness of cervical screening in lowering mortality, we must still recognize that the Pap test is only moderately accurate. Fortunately, the long preinvasive phase of cervical cancer and the successful public health initiatives that foster regular follow-up examinations lead to repeated opportunities to discover the neoplasm when it is curable. The NCCN Cervical Screening Clinical Practice Guidelines in Oncology provide a valuable roadmap for ensuring that appropriate steps are taken when routine examination shows abnormalities. A third factor leading to success has been the concerted educational and quality assurance programs to minimize laboratory variation and error. Therefore, noting the two major advances in the science of cervical screening in the past several years is gratifying: the use liquid-based cytology (LBC) to process Pap specimens and the use of human papillomavirus (HPV) testing to help guide the interpretation abnormal tests. In his review of the extensive trials comparing conventional Pap and LBC preparations, Cox notes that the new modality appears to be more sensitive in finding both low- and high-grade squamous...
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Rodger J. Winn

The standard definition of clinical practice guidelines explicitly states their aim as “to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances”.1 Over the past several years, the goal of allowing patients direct involvement in managing their health care has been pushed to the forefront, with the emphasis on shared decision-making2 and patient-centered care.3 The old paternalistic model of unassailable physician-directed recommendations is no longer a tenable approach.4 Patients are expected to understand the reasons for and consequences of the procedures they undergo and the care they receive to be able to decide between alternatives when available. Therefore, clinical practice guidelines, especially versions specifically designed for patient understanding, serve a valuable function in providing the information required for this informed decision-making.5 The implications of using guidelines recommendations as a vehicle for shared decision-making between caregiver and patient are both subtle and profound. If the guideline recommendations reflect only the judgments of a set of expert professionals, do they reflect the sum of the factors that should be considered in advancing those recommendations? Although the goal of any experts developing guidelines is to use the best available evidence in deriving recommendations, physicians recognize that the results of even high-powered clinical trials must be subjected to expert evaluation to ensure proper interpretation and that the results are congruent with other values and practical considerations.6 In the Ottawa Practice Guidelines Development Cycle, evidence-based recommendations derived by a panel of experts are sent to a broad range of practitioners for...
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Rodger J. Winn

This issue features a paper by Porter and Lange, “Controversies in the Surgical Management of Renal Cancer,” that highlights a major role for the oncology journal: examining the significant changes in treatment brought on by new technology. Taking on this task entails more than just describing the new procedure or device. To be of practical use to the clinician, the report must contain careful analysis of the multiple ramifications of introducing the new method or procedure. Radical nephrectomy has long been considered the appropriate management for renal cell cancer. Over recent years, increased use of partial nephrectomy and the introduction of laparoscopic techniques for performing radical nephrectomy have expanded the urologic oncologist's options. As one might suspect, the first consideration must be whether the new procedure is as good as the old in controlling the disease. In the case of the nephron-sparing procedure, observations in more than 2,600 patients indicate that for tumors less than 4 cm (and perhaps for tumors 4–7 cm), the control rates are the same as those achieved with the total organ excision. Similarly, multiple studies indicate that laparoscopic removal of the kidney achieves equivalent disease control to open approaches. If the cancer outcome is the same, how then should use of these new procedures be determined? In this instance, secondary outcomes become important. For partial nephrectomy, major postoperative morbidity is not increased despite the longer and more complex surgical procedure. What about the advantages? Studies suggest that overall renal function, as measured by creatinine levels,...
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Rodger J. Winn

Last November, the European Society for Medical Oncology/American Society of Clinical Oncology (ESMO/ASCO) Task Force on Global Curriculum in Medical Oncology published its recommendations.1 This comprehensive report detailed the elements trainees needed to assume a role in the multi-disciplinary milieu that is optimal oncologic care. Scanning these elements, I am immediately reminded that the knowledge required is considerably larger than just technologic expertise specific to administering drugs or managing chemotherapy-related complications. Rather, the practice of medical oncology today demands a broad orientation to all therapeutic modalities so that all team members appreciate the ramifications of each contribution to the overall management plan. For example, for soft tissue sarcomas, the curriculum calls for the trainee to “know the appropriate surgery for initial diagnosis and the indications for limb preservation.” At first glance, this requirement may seem fairly easy to achieve. However, as Randall and Gowski's article in this issue, on managing grade I chondrosarcoma of bone, shows, comprehensive management is far from routine or superficially addressed. The important clinical determination of a benign enchondroma from a low-grade chondrosarcoma carries with it major therapeutic implications, but data from a broad range of pathological and radiologic procedures still lead to a large diagnostic gray area. As an aside, the paper highlights why the NCCN guidelines recommend that sarcomas be managed by a team of professionals with expertise in sarcomas. Can a pathologist without vast experience distinguish between an “enchondromatous encasement pattern” and a pattern of hyaline or myxoid cartilage permeating lamellar...