Despite the increasing use of clinical practice guidelines to aid clinical decision-making, obstacles to the potential full use of guidelines still exist. Interestingly, 2 major barriers in the clinical context balance at opposite ends of the implementation spectrum.
The first obstacle is clinical inertia1—the failure to intensify treatment to achieve optimal targets. An oft-cited example in oncology is the finding that a substantial number (30%) of patients across a broad spectrum of clinical practices receive therapy with a relative dose intensity less than 85%. Perhaps even more puzzling, more than half of the under-treated patients are started at doses below those established in clinical trials.2 Hopefully the judicious use of quality improvement methods, including system and computerized checks, can overcome some of this inertia.
At the other end of the spectrum is what might be called the “My Big Fat Greek Wedding Windex phenomenon,” after the belief of one of the characters in that film that the cleaning product Windex could be used for almost everything. In oncology, the phenomenon suggests that once a modality is found useful in one situation, its use is indiscriminately disseminated to many other applications. Certainly, some of these applications are based on science, but others rest on more tenuous theoretic rationales.
In light of this obstacle, I found it refreshing that Mayer et al., in their paper on use of the new agent lapatinib in breast cancer, strike a cautionary note. They propose that lapatinib be used in patient groups for whom its efficacy...
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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.