Clinical Oncology (2007) 19: 591e592doi:10.1016/j.clon.2007.07.012

Editorial

Evidence Based Guidelines. Still Fit forPurpose or Past Their Sell By Date?

G. C. W. Howard*,1, P. J. Hoskiny*Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK; yMount Vernon Hospital,

Northwood, Middlesex HA6 2RN, UK

Only two decades or so ago opinions were formed andclinical practice shaped by text books, articles in peerreviewed journals, and attendance at meetings to listen toplenary lectures and scientific papers. This rather ad hocway of disseminating information not surprisingly resultedin a slow and patchy uptake of new treatments andtechnology, very much dependent on the interests andenthusiasm of individual clinicians. This process alsoallowed practitioners to act on data that supported theirown personal biases, a position many of us still find morecomfortable than confronting information that challengesour experience and beliefs. This is perhaps well illustratedin the range of radiotherapy fractionation schedules incurrent use [1].

On the fiftieth anniversary of the NHS an article in theFinancial Times announced that to celebrate ‘The govern-ment has come up with an exciting and revolutionary idea;doctors should concentrate on providing treatments thatwork’. The author also quoted a distinguished cardiologistwho had stated that the long held view that this threatenedclinical freedom was ‘‘at best a cloak for ignorance and atworst an excuse for quackery’’[2]. Evidence based medi-cine was up and running and an essential element in theprocess was the evidence based guideline (EBG). As withmany innovations the role of the EBG was misunderstood bymany, and therefore the expectations of what it could dowere often overestimated. It seemed that the EBG wouldtake over from all other ways of disseminating goodpractice and as a result there was almost a moratoriumon other educational techniques. The review or overviewwas seen to be no longer acceptable, the personal opinionand consensus view frowned upon, and the pendulumswung so far that single centre series were in many casesdeemed not publishable. All articles had to be evidencebased, and unless certain criteria were fulfilled to reassureus that this was the case they were rejected. In our opinionthis was a misuse of the tool called the EBG and a gross

1 Declaration of interest: GCW Howard is a member of SIGNCouncil and chair of the SIGN Cancer Subgroup.

0936-6555/07/190591þ02 $35.00/0 ª 2007 Pub

overreaction to its role in clinical medicine. Followinga period of initial enthusiasm the reality of what theseguidelines could and could not do, and in particular theresource required to write them became apparent andguideline fatigue began to set in.

At the same time more information was increasinglyavailable to practitioners and the public through theinternet. The use of the internet to seek information isanathema to the supporters of the evidence based guide-line. The information is unfiltered, not reviewed, of variablequality and open to bias. However, an evidence basedguideline will take at least 2 years to write and cost the NHS.The net is free and available to all.

Over the last few years this journal has contributed tothe debate on the role of guidelines in particular some ofthe cancer EBGs published by the Scottish IntercollegiateGuideline Network (SIGN) [3,4].

In this edition we have a detailed assessment of one ofthe SIGN guidelines [5] and a response from SIGN [6].Professors Reed’s editorial is a timely challenge to theconcept and role of the EBG and he introduces the ‘Googletest’. He concludes that for some topics a Google search isbetter than the guideline.

Does this mean that the days of the EBG are over and thatthe world wide web will tell clinicians and patients alikewhat is best practice in any given clinical situation? Theanswer clearly is no. Just as the randomised controlled trial(RCT), cannot answer all areas of clinical uncertainty but isa useful tool in certain circumstances, the EBG was nevermeant to solve all areas of uncertainty over best clinicalpractice. For well circumscribed areas of practice wherethere are variable outcomes, and a variation in practicewith data to support one intervention over another the EBGis undoubtedly the best tool to change practice in a timelyand coherent fashion and improve outcomes. These arehowever very tight criteria and just as there are questionswhich cannot be answered by RCTs the EBG is not a panaceato solve all areas of clinical uncertainty. As for those whofeel they limit clinical freedom and stop clinicians thinking.EBGs are to start, not stop, the thought process and aiddecision making not make decisions for you.

lished by Elsevier Ltd on behalf of The Royal College of Radiologists.

592 CLINICAL ONCOLOGY

The EBG is a tool which when used in appropriatecircumstances can be invaluable to change clinical practicein a beneficial way. Like all tools however if used for thewrong job will not behelpful and possibly counterproductive.

Guidelines define management according to rigid criteriausually based on parameters such as anatomical site,histology and stage of disease. However as clinicians weare faced with treating individuals with their complexity ofopinion, belief and co-morbidity. Flexibility based ona broad appreciation of the subject incorporating evidencefrom multiple sources is the only way to apply knowledge tothe recipient of our care, the patient. Indeed whilstanathema to devotees of the EBG there may even bea place for interpreting the facts against the backdrop of‘‘clinical experience’’ and compassion for the individual.Unfortunately there is a serious danger that this will be lostin the rigid MDT based practice pathways advocated bythose who understand process but not practice.

So the EBG and the MDM are both weapons in thearmamentarium that we as clinicians can use to improveservices to our patients. This does not have to be to theexclusion of others. There is a place for EBGs, there isa place for the internet and there is still a place forreviews, overviews, personal opinions and single centre

series. The challenge for us as oncologists is to know thestrengths and weaknesses of these different types ofinformation and to be able to interpret all these sourcesappropriately so that we can advise our patients wisely.

Author for correspondence: Dr. Grahame Howard, ConsultantClinical Oncologist, Western General Hospital, Edinburgh CancerCentre, Crewe Road, Edinburgh EH4 2XU, UK. Tel: þ44-1-31-537-2211; E-mail: grahame.howard@luht.scot.nhs.uk

References

1 Williams MV, James ND, Summers ET, Barrett A, Ash DV. NationalSurvey of Radiotherapy Fractionation Practice 2003. Clin Oncol2006;18:3e14.

2 Nicholas Timmins 1998. ‘‘A terrible beauty’’. The Financial Timesweekend July the 4th and 5th.

3 Howard GCW. Cancer Guidelines. Clin Oncol 2001;13:320e321.4 Neal DE. SIGN: No.85-Management of Transitional Cell carcinoma

of the Bladder. Clin Oncol 2006;18:700e701.5 Reed. National Clinical Guidelines for the management of Breast

cancer in Women. Scottish Intercollegiate Guidelines Network.Clin Oncol 2007;19:588e590.

6 Adamson DJA. Response from SIGN. Clin Oncol 2007;19:628.