1 Centre Léon Bérard, Lyon, France; 2 McMaster University, Hamilton, Ontario, Canada. *Standards, Options et Recommandations, FNCLCC, 101 rue de Tolbiac, 75654 Paris cedex 13, France (E-mail: fervers@lyon.fnclcc.fr)
The principles for the development of sound clinical practice guidelines (CPGs) are well established [1]. However, many published guidelines do not meet even basic quality criteria [2]. In addition, guideline development is costly and time consuming, particularly when updating guidelines is considered. Owing to limited budgets, European guidelines initiatives could benefit from collaboration to minimise costs and avoid duplication of effort.
Review and synthesis of evidence are key elements, which are costly and time-consuming, and most likely to benefit from collaboration. Other aspects of guideline development will require specific national or local input. The organisational and cultural diversity between European countries may lead to legitimate variability in guideline recommendations based on the same evidence [3]. Hence, it is important that the process leading to the recommendations is transparent and explicit, with a clear link between evidence and recommendations. The Guidelines Development Cycle published by Browman et al. [4] provides the basis for achieving both generalisable, evidence-based recommendations and local relevance for practice, which is crucial for successful implementation. The guideline quality appraisal instrument validated by the AGREE Collaboration (a European Union, Biomed II project) provides a framework for the development of guidelines (www.agreecollaboration.org).
CPGs in oncology have been shown to lead to changes in practice when dissemination and implementation are an integral part of the guideline development process [5, 6]. CPGs produced as part of a structured programme have significantly higher quality scores than those published outside a programme [7]. As a consequence, multinational co-operative projects should be built around structured approaches providing methodological support for guideline development and updating, as well as their dissemination and implementation. The collaboration between the French National Federation of Cancer Centres (FNCLCC) guidelines project Standards, Options and Recommendations [5] and the Cancer Care Ontario Guideline Initiative [4] provided insight into the challenges encountered when countries cooperate, and into the legitimate reasons for inconsistency of recommendations based on the same evidence.
The Minimal Clinical Recommendations (MCR) produced by the European Society for Medical Oncology (ESMO) [8] is one of the first initiatives to undertake the development of Europe-wide cancer guidelines. The ESMO Guidelines Task Force (in which two of us participated) decided to base the ESMO-MCR on existing CPGs. In view of the above issues, assessment of the ESMO-MCR using the AGREE instrument seems warranted. Such an examination demonstrates that ESMO-MCR publications [922] provide few, if any, details of the strategy used to search for published CPGs, or other evidence. Only four ESMO-MCR cite the references for the CPGs used [15, 16, 20, 22], and there has been little attempt to verify the quality of these existing guidelines. It is unclear how expert opinion was integrated in the formulation of recommendations and how these were linked to the supporting evidence. The experts themselves have a strong influence on the formulation of guideline recommendations, and multidisciplinarity is an important criterion in cancer care. However, the co-ordination of a given topic was assigned to a single medical oncologist, and while external review involved members of the ESMO faculty, there appeared to be no input from other medical or related health-care disciplines, including practitioners and other stakeholders.
If the ESMO-MCR are intended to be independent, evidence-based guidelines, they should comply strictly with the methodological standards for evidence-based guidelines. While this is not relevant for guidelines intended to be based on expert opinion as the main information source, non-compliance can seriously question the validity of CPGs that are intended to be evidence based. There is also concern about the ability of ESMO-MCR to influence practice because of the lack of a process to guarantee their relevance to national and local situations. If there is no added value, ESMO-MCR are likely to lead to duplication of effort and inefficient use of limited resources, including the time volunteered by experts.
Despite these reservations about the ESMO-MCR, the project has led to an examination of how this type of approach could be achieved in Europe. But, if it is worth doing, it is worth doing well. Promoting collaboration among guideline development initiatives in Europe involves learning: how to share CPG development and updating responsibilities at an international level; how to adopt common standards to improve the consistency and quality of guidelines; how to maximise the national relevance of shared guidelines; and how to provide an appropriate organisational framework. In addition, multinational collaboration could lead to a better understanding of the crucial factors of the guideline development process, and the determinants of high-quality guidelines.
Acknowledgements
The authors are indebted to Anne Bataillard and Margaret Haugh for their useful comments and assistance with editing.
B. Fervers1*, T. Philip1 & G. P. Browman2
1Centre Léon Bérard, Lyon, France; 2McMaster University, Hamilton, Ontario, Canada. *Standards, Options et Recommandations, FNCLCC, 101 rue de Tolbiac, 75654 Paris cedex 13, France (E-mail: fervers{at}lyon.fnclcc.fr)
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