Cancer Guidelines Disagree on Correct Care

November 23, 2014
Michael R. Page, PharmD, RPh

Clinical practice guidelines for the diagnosis and treatment of certain types of cancer are surprisingly unstandardized.

Clinical practice guidelines for the diagnosis and treatment of certain types of cancer are surprisingly unstandardized, according to a report published November 6, 2014, in the journal Cancer by Zaid M. Abdelsattar, MD, and colleagues at the University of Michigan Comprehensive Cancer Center.2

The researchers analyzed 5 recent guidelines published by organizations in Canada, Europe, and the United States for the treatment of rectal cancer, and then rated the quality of guidelines on the 23-item, 6-scale Appraisal of Guidelines Research & Evaluation (AGREE II) instrument. Four independent experts rated guidelines using the instrument, arriving at scores for the quality of each guideline’s scope and purpose, stakeholder involvement, rigor, clarity, applicability, and editorial independence. The overall AGREE II score rated the overall quality of each guideline as a percentage.2

The National Institute for Health and Clinical Excellence (NICE) clinical practice guidelines for the treatment of rectal cancer had the highest overall AGREE II score, at 90%, whereas the European Society for Medical Oncology (ESMO) guidelines garnered the lowest overall rating, at 27%.2

The American Society of Colon and Rectal Surgeons (ASCRS), Cancer Care Ontario (CCO), and NICE guidelines all shared the strength of basing recommendations on systematic reviews. On the other hand, the ESMO and National Comprehensive Cancer Network (NCCN) guidelines did not rely on systematic literature reviews in the process of development. Another reason for ESMO's low guideline rating was its low level of developmental rigor, which was rated at 17%, contrasting starkly with the NICE guideline's 96% rating on the same metric.1,2

On 21 key points, only 8 were widely agreed upon by all guidelines, and the guidelines provided contradictory recommendations on 6 points. Areas of clinical disagreement included the role of short-course radiation therapy in patients with moderate-risk rectal cancer, the duration of postoperative chemoradiation therapy in high-risk patients, the role of laparoscopic rectal surgery, and aftercare surveillance.1,2

"In this day and age of practicing medicine, particularly with cancer, physicians rely on these guidelines heavily. Our study suggests we need to be careful about that,” said senior author Sandra L. Wong, MD, MS, associate professor of surgery at the University of Michigan Medical School. “The guidelines are of varying quality and they have varying recommendations. It's not as easy as just viewing a guideline and following it.” 1,2

Even with the same randomized clinical trials and the same clinical evidence, guideline panels sometimes make vastly different recommendations. Dr. Wong advised health care professionals to interpret guidelines with caution, particularly those that do not meet Institute of Medicine (IOM) standards for production of high-quality guidelines.1-3

The IOM’s “Clinical Practice Guidelines We Can Trust” report published in March 2011 outlined a standardized method for the development of reliable clinical practice guidelines. The report authors recommended using systematic reviews, relying on the knowledge multidisciplinary expert panels, promoting transparency in guideline development, rating recommendations by the strength and the quality of evidence supporting their implementation, and setting up a system for regular revision of recommendations as new evidence becomes available.3

Clinicians rely on guidelines to synthesize a massive amount of data into coherent practice recommendations. Rating guidelines by the AGREE II criteria may lead to more international standardization, and may encourage guideline developers to produce guidelines based on accepted standards, as determined by the IOM.3


1. EurekAlert. Study finds wide variation in quality, content of clinical cancer guidelines. Accessed November 2014.

2. Abdelsattar ZM, Reames BN, Regenbogen SE, Hendren S, Wong SL. Critical evaluation of the scientific content in clinical practice guidelines. Cancer. 2014.

3. Graham R, Mancher M, Miller Wolman D, Greenfield S, Steinberg E, eds. Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press; 2011. Accessed November 2014.