Beyond Guidelines: Conventional Wisdom About Strict Adherence Can Be Misleading

Maurie Markman, MD
Published: Tuesday, Jun 18, 2013
Maurie Markman, MD

Maurie Markman, MD

Editor-in-Chief of OncologyLive

Senior vice president for Clinical Affairs and National Director for Medical Oncology

Cancer Treatment Centers of America, Eastern Regional Medical Center

In the classic Hans Christian Andersen children’s story, The Emperor’s New Clothes, two tailors fool the emperor into believing that they have made wonderful new clothes for him when in fact they have created nothing. When he goes outside wearing his imaginary outfit, his subjects are unwilling or unable to acknowledge the truth that the emperor is wearing no clothes, but a little child⎯ unaffected by what the adults all around him fail or refuse to see and oblivious to conventional wisdom on the subject of the monarch⎯pronounces: “But he has nothing on at all!”

Unfortunately, in the opinion of this commentator, the message of this wonderful children’s story can be applied to an important misconception in certain epidemiologic studies in the cancer arena related to conclusions drawn from possible relationships between two independent clinical events. The problem arises when either a study investigator or individuals not involved with the particular study (eg, lay media) confuse what is observed to be a possible association between the events as actually representing a clear direct cause-and-effect relationship between one of the events and the other.

Consider, for a moment, a recent editorial in The New York Times1 that discussed an abstract presented at the 2013 annual meeting of the Society of Gynecologic Oncology dealing with a population-based study on the management of epithelial ovarian cancer.2 The editorial noted that the study found “only 37% (of patients) received the care recommended in guidelines set by the National Comprehensive Cancer Network [NCCN].” It further commented that “this kind of failure is not uncommon in American medicine,” and “in the case of ovarian cancer, the consequences of inadequate care are tragic.”1

While it is impossible to disagree with this general sentiment regarding the importance of adequate care for all cancer patients, including women with ovarian cancer, and to emphasize the critical relevance of efforts undertaken at the national, regional, and local hospital levels to optimize the quality of cancer care, the question to be addressed in this commentary is what specifically in this particular research project provides solid evidence to support the conclusion that the percentage of patients who did not receive care recommended in NCCN guidelines actually represents “inadequate care.”

In fact, a competent surgical or medical physician caring for a woman with ovarian cancer who utilizes her/ his clinical skills and experiences (the process of clinical judgment) may quite appropriately decide that⎯based on the particular patient’s medical status including her physiologic age, relevant and serious comorbidities, or the extent of her disease⎯it would not be in that individual’s best interest for her to undergo guideline-based therapy. The guidelines call for an attempt at aggressive/ maximal surgical cytoreduction followed by combination platinum-based cytotoxic chemotherapy.

Guideline Adherence and Survival in Epithelial Ovarian Cancer

Patients receiving guideline-based therapy experience superior survival compared with patients not treated based on guidelines.
Cause-and-effect explanation Association explanation
Treatment based on guidelines is the reason for the favorable outcome. The decision to not employ guidelines is largely based on clinical judgment that particular patients are not appropriate for that strategy.

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