Online Exclusive - January 26, 2009
ASCO strives to promote the use of consistent, evidence-based medicine in oncology practice to improve treatments and outcomes for patients with cancer. Clinical Practice Guidelines are a key part of the Society’s efforts to provide access for all oncologists to information on the most effective methods in the prevention, diagnosis, and treatment of cancer. In the interview that follows, Richard Theriault, DO, Chair of the Health Services Committee, discusses the role that Guidelines play in shaping oncology practice and the Committee’s work in creating them.
AN&F: How does the Health Services Committee select topics for ASCO’s Clinical Practice Guidelines?
Dr. Theriault: Any ASCO member can suggest a topic for a guideline. So far, the majority of the guidelines have come from suggestions made by members to people on the Health Services Committee. We do not hold a regular solicitation for guideline suggestions, but once a topic is suggested, we have to see whether or not there are enough data from which to develop a guideline. Because the guidelines are evidence-based, we perform a systematic review of the literature, which can take a significant amount of time to complete. The HER2 guideline (ASCO/College of American Pathologists Guideline Recommendations for Human Epidermal Growth Factor Receptor HER2 Testing in Breast Cancer) took approximately 14 months to put together. It depends on the activities of the panel and the panel chairs, and it also depends on the availability of ASCO’s in-house staff to conduct a systematic review.
AN&F: Why create Guidelines? What needs of today’s oncologists does ASCO hope to address?
Dr. Theriault: The first thing ASCO hopes to create with the guidelines is an authoritative resource for practicing oncologists. We hope to provide some guidance and structure about quality of care, and ensure that the guidelines serve an educational purpose as well as an academic purpose.
Why create guidelines? The major reason is because cancer care is so complex. As our knowledge of the biology, molecular biology, and genetics of cancer increases, the complexities of the treatment decision process increase as well. Also, the sequencing of treatments, whether they’re local, regional, biologic, chemo-, or endocrine therapies, has become challenging. Applying all of this science for a patient in a particular circumstance is the art of the oncologist. If oncologists have a guideline that can help them perhaps structure their thinking, we are hopeful that it can create an outcome of good quality care.
AN&F: What are some of the areas of oncology that require the greatest attention from organizations like ASCO?
Dr. Theriault: The subject of greatest attention must be the focus we place on the patient with cancer. We must make the correct biologic decision for the cancer that presents, but also the correct human decision for the person that we’re treating. And in this regard, the development of quality measures, as we’ve had with the QOPI™ program, has been helpful in educating people about what we think is good care. The concept of good care is subject to change as new knowledge is uncovered, but right now, our guidelines represent what we think of as good care. So I think focusing on the patient, the biologic correctness of decisions, and the human aspect of what the patient considers to be good is the primary thing for me as a practicing oncologist.
AN&F: What upcoming guidelines will be particularly helpful for oncologists?
Dr. Theriault: The Health Services Committee is working on some things with cancer risk reduction. We have two upcoming guidelines on chemoprevention, including one that is an update of the Breast Cancer Risk Reduction guideline.
Also, we’re going to incorporate information on health disparities into each of our guidelines. Everyone is aware that socioeconomically deprived people in certain self-reported racial and ethnic groups experience disparities in health care, whether it is access or treatment or any other challenge. But are there data about that that we could include in the guidelines that would help inform the physicians who care for these patients? And if there aren’t any data, does that mean that we should do more research? These are issues that the Committee hopes to address with the inclusion of this kind of information in the guidelines.
We’ve just begun to work on a guideline on testing for estrogen and progesterone receptors, similar to the HER2 testing guideline. This will be a tremendous challenge because the amount of data available for a systematic review on this topic is thousands of papers, spanning topics from technical aspects to tissue care to application decisions and decision analysis. It’s going to be quite a challenge.
AN&F: How has the Health Services Committee worked to make the guidelines more useful in everyday practice?
Dr. Theriault: The Guideline Clinical Tools and Resources website www.asco.org/guidelines/clinical tools.html contains summaries of the guidelines, slide sets for use with the guidelines, a number of clinical tools like flow sheets for the guidelines, and also patient guides on how to use the guidelines and how to instruct patients on their significance, as well as information ASCO writes for patients. The “toolbox” provides this information for a number of different kinds of cancers. They are available to anyone.
Personally, I like the guideline summaries. Some of our guidelines tend to be very academic and are written in academic prose. They can be very dense. But the guideline summaries are very handy to use as a reference.
We also have a GuIDE (guidelines implementation, dissemination, and evaluation) subcommittee, whose role is to develop methods for the dissemination, education, and application of the guidelines throughout ASCO and for all practicing oncologists.
AN&F: How does the Health Services Committee help ASCO promote quality cancer care through the guidelines?
Dr. Theriault: The Health Services Committee is a terrific group of people who volunteer their time and who are very attentive and diligent in their work. They are supported by a fantastic staff at ASCO headquarters, who do all of the background work for us. We’re a decision-making body, and behind the scenes is the ASCO staff that gives us a lot of help.
I think the Committee is a very laudable and multidisciplinary group that includes experts in decision analysis, biostatistics, quality indicators, as well as surgeons, radiation, and medical oncologists, and also community and academic physicians. It’s a very broad group of volunteers to do this and helps produce great work.
Update On the Use of Chemotherapy and Radiotherapy Protectants
ASCO first updated its guideline on chemotherapy and radiotherapy protectants in 2002; the current updated version reflects a review of new evidence published since then. The 2008 guideline update adds two new sections. The first reviews evidence on a new agent, palifermin, a recombinant keratinocyte growth factor. Palifermin is recommended for the prevention of mucositis in people with hematologic cancers receiving autologous or myeloablative allogeneic hematopoietic stem cell transplantation with a total body irradiation conditioning regimen. It is not recommended for chemotherapy-only conditioning regimens, in the non-stem cell transplant setting, or with treatment for solid tumors.
In the second new section, the guideline reviews published data regarding the use of amifostine to prevent esophagitis and states that data are insufficient to recommend its routine use for this purpose. The evidence is based on studies of chemoradiotherapy for non-small cell lung cancer.
Many of the recommendations contained in the previous version of this guideline remain unchanged in the updated version. For a complete list of recommendations, please view the Update Table at www.asco.org/guidelines/protectants. The site also provides the full-text guideline, a guideline summary, and a slide set.
Reference
- Kolata G. “New Take of a Prostate Drug, and a New Debate.” New York Times. June 15, 2008.
