A comparison of international breast cancer guidelines – Do the national guidelines differ in treatment recommendations?

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Abstract

Aim of the study

Clinical practice guidelines (CPG) are an appropriate method to optimise routine clinical care. Numerous CPGs for the diagnosis and treatment of breast cancer have been developed by national health institutions or medical societies. While a comparison of methodological criteria has been undertaken before, it is unknown whether these CPGs differ in their actual treatment recommendations.

Methods

We included national breast cancer CPGs from the USA, Canada, Australia, the UK, and Germany that satisfy internationally recognised methodological criteria and are in widespread use in daily clinical care. Treatment recommendations for adjuvant invasive breast cancer including surgery, radiation, endocrine therapy, chemotherapy and anti-HER2-therapy were compared.

Results

Recommendations for endocrine therapy show discordances regarding optimal usage of ovarian function suppression for premenopausal patients and aromatase inhibitors for postmenopausal patients. However, most other treatment recommendations exhibit a large degree of congruency. This reflects the fact that they rest on the same evidence base, and that many national guidelines are adopted from other guidelines so that well accepted guidelines are cited within other guidelines.

Concluding statement

Considering that the development of guidelines is a very expensive and resource-intensive task the question arises whether the development of national guidelines in numerous countries is worth the effort since the recommendations differ only marginally.

Introduction

Worldwide clinical practice guidelines (CPG) are being developed in all fields of medicine in order to optimise the quality of patient care.1, 2 CPGs exhibit an increasing level of methodological quality due to advanced achievements in health services research (e.g. AGREE II, Appraisal of Guidelines for Research and Evaluation). High-quality evidence-based guidelines are becoming more and more standard practice.3 However, it is controversial whether high methodological quality of CPG corresponds with the level of validity of the recommendations.4 In addition, the effectiveness of guidelines depends not solely on the quality of the guideline but also on dissemination and implementation strategies. The ideal way to enforce the application of CPG is controversial5 and is highly dependent on the national health care system as well as on the specific content of the CPG.

Recently health services research has focused on the analysis of CPG effects. While improvements in the process of care have been shown in different settings,2, 6 effectiveness in terms of better health outcome for the individual patient has as yet been insufficiently studied.7, 8 For the management of early breast cancer, we have previously shown that adherence to CPG improves the outcome significantly.9

As breast cancer is the most common female cancer type and is a primary health care problem in the field of oncology, numerous CPG have been developed. More than 140 evidence-based documents under the keyword of breast cancer are specified at the Guideline International Network, and about 70 of them are CPGs. Nevertheless to date no comparison of the contents of breast cancer guidelines frequently used on an international scale exists. Therefore, we systematically compared the recommendations and statements regarding the treatment modalities of surgery, radiotherapy and systemic therapy in early breast cancer in the following CPGs (Table 1).

Apart from some discordance especially in the recommendations regarding endocrine treatment, we have found large congruency between the analysed CPGs, which reflects the fact that the recommendations are mainly based on the same evidence. This raises the question whether the development of national guidelines in numerous countries and organisations should be encouraged in the future.

Section snippets

Methods

The aim of this study was not to analyse comprehensively all existing national breast cancer guidelines but we rather focused on those widely used in the daily care setting of oncology and satisfying internationally recognised methodological criteria (e.g. validity, reproducibility, reliability, representative development, clinical applicability, clinical flexibility, clarity, meticulous documentation, scheduled review).28, 29 All selected guidelines were published between 2001 and 2011 (Fig. 1

Results

The recommendations of all included national CPGs for surgery, radiotherapy and systemic adjuvant therapy were compared and analysed for their congruency.

Discussion

More than 70 evidence-based documents specified at the Guidelines International Network under the keyword of breast cancer are CPGs. While a methodological analysis of a number of national breast cancer guidelines was recently undertaken by the German Institute for Quality and Efficiency in Health Care (IQWIG),28 a direct comparison of the content of treatment related recommendations has not been made so far.

Our analysis of the most relevant therapeutic modalities revealed a large congruency of

Conflict of interest statement

None declared.

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    d

    Both authors contributed equally to this manuscript.

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