Cancer clinical guidelines fall short of IOM standards

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The vast majority of oncology clinical practice guidelines (CPGs) fail to meet the Institute of Medicine (IOM) standards for trustworthy guidelines, according to a recent evaluation published by Journal of Clinical Oncology.

The March 2011 IOM report, Clinical Practice Guidelines We Can Trust, established standards for developing trustworthy CPGs. The standards set forth eight criteria covering the disclosure of conflicts of interest, the use of systematic literature reviews, the use of external review, and the regular updating of recommendations.

A team led by Sandra L. Wong, MD, MS, of the University of Michigan Comprehensive Cancer Center in Ann Arbor, Michigan, employed those standards as a benchmark to assess oncology CPGs and consensus statements. These documents, all published between January 2005 and December 2010, addressed the screening, evaluation, or management of the four leading causes of cancer mortality in the United States: lung, breast, prostate, and colorectal cancers.

The evaluation revealed the following:

  • None of the 169 CPGs analyzed fully met all IOM standards.
  • The average overall scores were 2.75 of eight possible standards and 8.24 of 20 possible subcriteria.
  • Fewer than half of the CPGs were based on a systematic review.
  • Only half the CPG panels addressed conflicts of interest.
  • Most CPGs did not comply with standards for inclusion of patient and public involvement in the development or review process, nor did they specify their process for updating.
  • CPGs were most consistent with IOM standards for transparency, articulation of recommendations, and use of external review.

Based on these results, Wong and colleagues determined that much work is still needed to make guidelines as methodologically sound and evidence-based as possible. However, as Wong pointed out in an accompanying statement from the University of Michigan Health System, some of the guidelines she and her team studied are “really good,” and it is possible that the IOM guidelines might be too strict.

“If a group does not include a forum for public comment on the guidelines, does that make the guideline less trustworthy? Is that as important as whether they incorporate a systematic review of the literature?” queried Wong in the statement, adding that perhaps not all standards should be weighted the same across the board.

Wong also suggested finding a balance between ideal standards and what is practical to ensure that guidelines can be put in place in a timely manner, as some already take more than a year to create.
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