Comparison of international breast cancer guidelines: are we globally consistent? cancer guideline AGREEment

Abstract

Background: Evidence-based guidelines are used in health care systems throughout the world to aid in treatment decisions and to ensure quality and consistency in patient care. In breast oncology, guidelines for care are published by several internationally recognized organizations, including those from the United States, Canada, and the United Kingdom. The present study compared clinical breast cancer guidelines from the American Society of Clinical Oncology (ASCO, United States), Cancer Care Ontario (CCO, Canada), and the National Institute for Health and Clinical Excellence (NICE, United Kingdom) to determine the quality and consistency of content across international organizations.

Methods: We searched for breast cancer guidelines published by ASCO, CCO, and NICE. Guidelines on the same theme were identified across organizations and appraised by 4 independent reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. Content of each guideline was also scored for consistency in overall recommendations across organizations and for consistency in cited evidence.

Results: The quality of breast cancer guidelines produced by the targeted organizations was consistently good in the areas of Scope and Purpose, Rigor of Development, and Clarity and Presentation, but variable in the domains of Stakeholder Involvement, Applicability, and Editorial Independence. The content of the guidelines varied slightly in the strength of their recommendations.

Conclusions: Our review demonstrated consistency in quality and content for breast cancer practice guidelines published by various organizations. Future guidelines developed by these organizations should focus on how to implement and measure uptake of a guideline.

Keywords: Breast cancer; agree instrument; practice guidelines; quality of care.

FIGURE 1

Guidelines on similar themes across organizations. The American Society of Clinical Oncology (asco) published 9 breast cancer guidelines, 3 of which had themes in common only with those from the U.K. National Institute for Health and Clinical Excellence (nice), which published 22 breast cancer guidelines in total. Cancer Care Ontario (cco) published 19 breast cancer guidelines, 15 of which shared common themes only with those from nice. Among the three organizations, 3 guidelines shared a common theme.

FIGURE 2

(A) Guidelines on the use of adjuvant aromatase inhibitors (ais). Scores for the guidelines on use of ais were lowest and showed the most variability across organizations in the domain of Applicability. Guidelines from Cancer Care Ontario (cco) had the highest scores in the domains of Scope and Purpose, Rigour of Development, and Editorial Independence. The U.K. National Institute for Health and Clinical Excellence (nice) had the lowest scores in those areas. (B) Guidelines for staging investigations and follow-up. Scores for these guidelines were slightly more consistent between organizations. The U.K. National Institute for Health and Clinical Excellence scored highest most often; the American Society of Clinical Oncology (asco) scored lowest in every domain except the domain of Editorial Independence. (C) Guidelines on bisphosphonate use in metastatic breast cancer. The scores for these guidelines were the most consistent. Once again, the domain of Applicability showed the greatest variability, but not necessarily the lowest scores, which were seen in the domain of Editorial Independence.

FIGURE 3

(A) Breast cancer guidelines from the American Society of Clinical Oncology. The scores for these guidelines varied most in the domain of Applicability and least in the domain of Stakeholder Involvement. The lowest scores for all guidelines from any organization are seen here, including an 8% in the domain of Applicability for the guideline on the use of adjuvant aromatase inhibitors. (B) Breast cancer guidelines from Cancer Care Ontario. The scores for these guidelines varied considerably in the domain of Editorial Independence. The lowest score was 29% in that domain for the guideline on bisphosphonate use. (C) Breast cancer guidelines from the U.K. National Institute for Health and Clinical Excellence. The Institute consistently scored higher overall. The scores were generally lower for guidelines on the use of adjuvant aromatase inhibitors than for guidelines on staging investigations and follow-up. ai = use of adjuvant aromatase inhibitors; sfu = staging investigations and follow-up; bp = bisphosphonate use.