Journal of Oncology Practice, Vol 4, No 5 (September), 2008: pp. 236-237
© 2008
American Society of Clinical Oncology.
DOI: 10.1200/JOP.0851501
ASCO Clinical Practice Guidelines: Past, Present and Future
Gary H. Lyman, MD, MPH, FRCP(Edin)
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Gary H. Lyman, MD, MPH, FRCP(Edin)
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American Society of Clinical Oncology (ASCO) clinical practice guidelines have been viewed as among the most valuable benefits of ASCO membership, surpassed only by the Annual Meeting and Journal of Clinical Oncology (JCO). Five of the top ten most frequently accessed in JCO are ASCO clinical practice guidelines. During the past 15 years, ASCO has published some 25 guidelines or technology assessments under the auspices of the Health Services Committee (HSC) and the approval of the ASCO Board of Directors. Though clearly a valuable component of ASCO membership, important limitations of the guidelines have also been pointed out, including their limited number, lack of frequent updates, and difficult implementation in daily practice, among other weaknesses. The strengths and limitations of ASCO clinical practice guidelines along with efforts recently initiated or planned to enhance the ASCO guideline process were recently summarized in a Special Article by Somerfield et al1 in the August 20 issue of JCO. The authors note that ASCO guidelines are often viewed as out of date, difficult to locate, and awkward to implement in everyday clinical oncology practice. Though these limitations are not unique to ASCO guidelines, the HSC has taken steps to improve the ASCO guideline process and final product.
The challenge of frequent updates to clinical practice guidelines is greatest with those, like ASCO guidelines, that are intensely evidence-based. For more than 5 years, ASCO clinical practice guideline recommendations have been premised on exhaustive systematic reviews of the literature, addressing a limited number of specific clinical questions, and guided by explicit and transparent criteria for study selection, data extraction, and analysis.2–4 According to Somerfield et al, referencing a recent Institute of Medicine report, such systematic reviews represent the central link between scientific evidence and clinical decision making.5 The specific approach to systematic reviews and ASCO guideline development are summarized in the ASCO Guideline Procedures Manual.6
In an effort to enhance and streamline the ASCO guideline process, several rapid updating options have been developed based on an annual assessment of the literature for each guideline (Table 1). When the literature search results in no change in practice recommendations due to either no new evidence (option 1) or no new evidence requiring a change in recommendations (option 2), an e-update with a summary and the inclusive dates of the literature search will be published in both JCO and the Journal of Oncology Practice (JOP). When new evidence supporting a practice guideline change is identified (option 3), a full update will be published in JCO and on the JCO Web site with summaries and derivative products provided in JOP. Finally, expedited ad hoc updates will be implemented when new evidence becomes available or regulatory changes occur that are judged to warrant changes in practice (option 4). The new recommendations and the evidence supporting these changes will be published as an alert on the ASCO Web site without need for a formal update of the entire guideline and evidence base.
Calls for additional ASCO guidelines and updates of previous guidelines that addressed a broad range of clinical questions represent continuing challenges to the integrity of the current rigorous ASCO guideline process. In an effort to address the call for additional high-quality ASCO approved guidelines, the Board of Directors has approved a procedure for ASCO endorsement of practice guidelines developed by other professional organizations and based on acceptable systematic reviews of the literature not supported by industry.12 Finally, Somerfield et al1 discuss the continuing challenge of guideline dissemination and implementation. Considerable efforts have been made in recent years to improve the accessibility and clinical utility of the ASCO clinical practice guidelines.13 ASCO guidelines are not only published in JCO but also available on the ASCO Web site (www.asco.org/guidelines) by disease site, ordered by publication date. In addition to the full guideline text, a number of guideline clinical tools and resources have been developed14 including guideline summaries and flow sheets published as tear-out pages in JOP, downloadable PowerPoint slide sets, and patient guides available at www.asco.org and www.cancer.net.
Though challenges remain, the primary goal of the ASCO guidelines program is to provide members with methodologically rigorous recommendations on important and sometimes controversial topics. Among the most important challenges noted by Somerfield1 is that of populating guideline panels with experts consistent with the current ASCO conflicts of interest policy, which requires a majority of panel members not have any relevant relationships with industry. Though such a policy is essential to ensure public and professional confidence in the validity of ASCO guidelines, it does limit access to many content experts on guideline topics, which is further limited by recent reductions in federal funding of clinical cancer research. To facilitate the goals of better dissemination and implementation, a comprehensive plan for evaluating the guidelines program and improving the utility of the clinical tools is being developed jointly by the HSC through the Guideline Implementation, Dissemination, and Evaluation Subcommittee and the ASCO Clinical Practice Committee. The ultimate goal of all of these efforts is to maximize the impact of ASCO clinical guidelines on clinical practice and the quality of cancer patient care.
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Notes
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Gary H. Lyman, MD, MPH, FRCP(Edin) is Associate Editor, Journal of Oncology Practice, and Professor of Medicine, Duke University School of Medicine and the Duke Comprehensive Cancer Center, Durham, NC. 
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References
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- Somerfield MR, Einhaus K, Hagerty KL, et al: American Society of Clinical Oncology clinical practice guidelines: Opportunities and challenges. J Clin Oncol 26:4022-4026, 2008[Abstract/Free Full Text]
- Kim T, Giuliano AE, Lyman GH: Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: A meta-analysis. Cancer 106:4-16, 2006[CrossRef][Medline]
- Kuderer NM, Dale DC, Crawford J, et al: Impact of primary prophylaxis with granulocyte colony-stimulating factor on febrile neutropenia and mortality in adult cancer patients receiving chemotherapy: A systematic review. J Clin Oncol 25:3158-3167, 2007[Abstract/Free Full Text]
- Kuderer NM, Khorana AA, Lyman GH, et al: A meta-analysis and systematic review of the efficacy and safety of anticoagulants as cancer treatment: Impact on survival and bleeding complications. Cancer 110:1149-1161, 2007[CrossRef][Medline]
- Knowing What Works in Health Care: A Roadmap for the Nation in Eden J, Wheatley B, McNeil B, et al (eds.).Washington, DC, Institute of Medicine, 2008
- American Society of Clinical Oncology Health Services Committee: ASCO Guideline Procedures Manual. www.asco.org/guidelines/manual
- Schrag D, Garewal HS, Burstein HJ, et al: American Society of Clinical Oncology technology assessment: Chemotherapy sensitivity and resistance assays. J Clin Oncol 22:3631-3638, 2004[Abstract/Free Full Text]
- Schrag D, Rifas-Shiman S, Saltz L, et al: Adjuvant chemotherapy use for medicare beneficiaries with stage II colon cancer. J Clin Oncol 20:3999-4005, 2002[Abstract/Free Full Text]
- Rizzo DJ, Somerfield MR, Hagerty KL, et al: Use of epoetin and darbepoetin in patients with cancer: 2007 American Society of Clinical Oncology/American Society of Hematology clinical practice guideline update. J Clin Oncol 26:132-149, 2008[Abstract/Free Full Text]
- Pfister DG, Johnson DH, Azzoli CG, et al: American Society of Clinical Oncology treatment of unresectable non–small-cell lung cancer guideline: Update 2003. J Clin Oncol 22:330-353, 2004[Free Full Text]
- FDA annoucement RE: gefitnib (IressaR) evolving safety information. http://www.asco.org/ASCO/Practice+Resources/Practice+Management/FDA+Drug+Alerts/FDA+annoucement+RE%3A+gefitnib+%28IressaR%29+evolving+safety+information
- Basch EM, Somerfield MR, Beer TM, et al: American Society of Clinical Oncology endorsement of the Cancer Care Ontario Practice Guideline on nonhormonal therapy for men with metastatic hormone-refractory (castration-resistant) prostate cancer. J Clin Oncol 25:5313-5318, 2007[Abstract/Free Full Text]
- Lyman GH: ASCO clinical practice guidelines and beyond. J Oncol Pract 3:330-331, 2007[Free Full Text]
- Wolff AC, Desch CE: Clinical practice guidelines in oncology: Translating evidence into practice (and back). J Oncol Pract 1:160-161, 2005[Free Full Text]
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