Whose Guidelines are they Anyway?

What is the Best Way to Produce Consensus and Buy in to Guidelines for Rectal Cancer?

Evidence-based guidelines are important tools and common pathways for translating evidence into clinical practice. It is most urgently needed when significant heterogeneity in practice exist. Actively engaging opinion leaders in the process of evidence-based guidelines development is important for several reasons. These include allowing the collective views of the practice communities to be represented, resolving heterogeneity in practice through discussion, and allowing credible recommendations to be formulated. Most importantly, the process itself is a tool for facilitating dissemination and implementation. Recognizing the gap between practice pattern and guideline recommendations, and devising strategies to address it represent an important step toward maximizing concordance between guideline and practice. Evidence-based recommendations serve as important reference points, against which we can measure, debate, and innovate from.

Do patients consider preoperative chemoradiation for primary rectal cancer worthwhile?

BACKGROUND

The objective of this study was to elicit future patients' preferences for preoperative chemoradiation (pre-CRT) for rectal cancer to determine whether patients' preferences are consistent with current treatment guidelines.

METHODS

During a standardized interview, the treatment protocol, risks, benefits, and long-term outcomes associated with 1) surgery alone (SA) and 2) pre-CRT followed by surgery (CR + S) were described to healthy individuals, and a threshold task was performed. Each participant was asked which treatment option they would prefer when the risk of local recurrence was set initially at 15% for both options. If the participant indicated SA (which was expected), then the risk of local recurrence for CR + S was lowered systematically until the participant's preference changed from SA to CR + S. This threshold point represented the risk of local recurrence for pre-CRT that the participant would require before they would choose treatment with pre-CRT.

RESULTS

Fifty individuals participated in the study, and the majority were well educated. Twenty-seven of 50 participants (54%) required a risk of local recurrence with CR + S of ≤ 5% (ie, equivalent to an absolute risk reduction ≥ 10%) before they would choose treatment with pre-CRT. Regression analysis did not identify any variables that were predictive of the participants' preferences.

CONCLUSIONS

Participants seemed to highly value functional outcomes and seemed willing to accept a higher risk of local recurrence to achieve this. Therefore, developers of future guidelines may need to downgrade the use of pre-CRT for all patients with stage II/III tumors from a guideline to an option.