Clinical Practice Guidelines: Still a Way to Go

Author: Rodger J. Winn MD
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This month's issue provides the journal reader with an elegant analysis of the clinical evidence substantiating the use of aromatase inhibitors (AIs) in the adjuvant treatment of breast cancer in postmenopausal women. Based on the data from 6 randomized studies, women may be treated with an AI alone, with 2 or 3 years of tamoxifen followed by an AI, or with 5 years of tamoxifen followed by another extended period of an AI. As this issue's special feature by Carlson et al. points out, the NCCN guidelines, the ASCO Technology Assessment, and the St Gallen consensus statement all recommend these 3 options. All 3 documents also state that existing data do not allow a choice among these approaches because they have not been compared head-to-head.In the broadest sense, all 3 panels agree that AIs offer a benefit, but the recommendations are not identical. The St Gallen recommendations also present a fourth option, the use of standard tamoxifen in patients at minimal or intermediate risk. The NCCN, in turn, does not recommend adjuvant treatment for very small lesions. As Baum and Ravdin1 previously observed, patients in the same clinical category could potentially be treated differently based on which clinical guideline their practitioner consulted.Why this disparity? Several differences in the guideline development process may account for it. The first and most obvious reason is that the panels can interpret data differently or attribute differing validity to the studies.2 This does not appear to be the case in this instance. A...

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Rodger J. Winn is the Co-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.

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    Baum M, Ravdin PM. Decision-making in early breast cancer: guidelines and decision tools. Eur J Cancer 2002;38:745749.

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    Davidson NE, Levine M. Breast cancer consensus meetings: Vive le difference? J Clin Oncol 2002;20:17191720.

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    Browman GP, Levine MN, Mohide EA. The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol 1995;13:502512.

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