Reviewers: John Han-Chih Chang, MD and Kenneth Blank, MD
Source: The Journal of the American Medical Association 1997; Volume 278: pages 1591 - 95
In most European countries, medical (especially cancer) care isusually centralized in a few large hospitals. But as with mostmedical centers around the world, physicians who staff these centerscome from various backgrounds of training with their selectivebiases. Thus treatment of a certain disease could be adequatelypursued in a number of different ways. In an effort to unify thetreatment scheme, groups of physicians have introduced clinicalpractice guidelines (CPG). Essentially, these are treatment flowdiagrams that dictate how to approach, diagnosis, and treat a patientwith a certain disease. The intent is to use the establishedliterature to guide diagnostic and treatment decisions. Thispractice has been utilized for many years by numerous physicians andmedical institutions.
Between 1993 and 1994, the physicians at Leon Berard (a Frenchcomprehensive cancer center) developed and implemented their CPG's. Two patient populations (localized breast and colon cancer) wereassessed with computerized records for compliance to the establishedguidelines.
Ninety-nine and one hundred patients randomly selected withlocalized breast cancer treated in 1993 and 1995 were assessed,respectively. The median ages were 55 and 51 years, respectively. Most were T1 lesions with no nodal involvement. Most had positivehormone receptor status and a Karnofsky performance status greaterthan 70.
Fifty-five and seventy-three patients with colon cancer treated in1993 and 1995 were assessed, respectively. Nearly all patients withcolon cancer were selected. The median ages were 60 and 62 years,respectively. Asler and Coller stage D described most of the coloncancer patients. Performance status was greater than 70 for most.
They also analyzed treatment decisions that strayed from theCPG's but abided by established literature that justified theirchoice. They deemed this treatment based on "scientific evidence."
The compliance rate with CPG's in overall treatment sequencefor the breast cancer group was 54% versus 19% in 1995 versus 1993,respectively (p < 0.001). Main significant differences in the twoyears in CPG compliance was seen in the chemotherapy, radiotherapy,hormonal therapy and follow-up. The compliance rate overall to CPG'sand/or "scientific evidence" was 68% versus 42%, respectively.
The compliance rate with CPG's in overall treatment sequencefor the colon cancer patients was 70% versus 50% in 1995 versus 1993,respectively (p = 0.009). Main significant differences in the twoyears in CPG compliance was noted in the chemotherapy only. Thecompliance rate overall to CPG's and/or "scientific evidence" was 81%versus 71%, respectively.
This article describes the experience at the Frenchcomprehensive cancer center. Their attempt at unifying diagnosticand treatment decisions has been somewhat successful. It seems thatthere has been a significant trend in adhering to the CPG's. They donot, however, detail their guidelines. The compliance is not 100%,as should be expected, since not all patients are going to fallideally into the flow diagram. One must continue to individualizedcare as each patient is unique. This study was not designed tofathom out, but a look at the impact of CPG's on outcome (localcontrol, disease free survival, overall survival and complicationrates) would be very interesting.