Spotlight: Emphasising the Practice in the ESMO Clinical Practice Guidelines

The ESMO Clinical Practice Guidelines (CPGs) are used by clinicians around the world and reflect the Society’s commitment to integrated and sustainable cancer care. ESMO recently made the decision to enhance the practice element of the CPGs in order to ensure that they remain useful for clinicians who are facing increasingly demanding work schedules. Has this change been successful? Read on to find out what those creating the guidelines and those using them in clinical practice think.

  • Date: 27 Mar 2018

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Optimising patient management and outcomes

Why did ESMO decide to enhance the practice element of the CPGs?

pentheroudakis-george

George Pentheroudakis Ioannina University Hospital, Greece; ESMO Executive Board Member; ESMO Guidelines Committee Chair 

The ESMO CPGs are high-quality, evidence-based, multidisciplinary, peer-reviewed guidelines, developed to facilitate the optimal treatment of the patient with cancer. Although they can assist in policy decision-making or reimbursement decisions, this is not their primary purpose. Addressing a pan-European (and, more recently, global) audience, the CPGs target cancer health professionals practising oncology across different settings. The decision to enhance the practice element of the guidelines was a logical consequence of this goal and was intended to optimise the management and health outcomes of the patient with cancer in a time of limited resources and competing policies.

How has the practice element of the CPGs been improved?

Basically, we’ve tried to make it easier for practising clinicians to access the information they want more quickly and to guide them through the various management options. All ESMO CPGs now feature standardised tables and algorithms that describe the diagnostic work-up and staging procedures, the use of validated biomarkers and risk- or stage-adapted management strategies. The pivotal management flow charts are an integral element of all ESMO guidelines and are colour-coded for ease of interpretation: red for surgery, green for radiotherapy and blue for systemic therapy. Each guideline also contains a bullet-pointed summary table of the recommendations. We are also coordinating guidelines from  Consensus Conferences, based on the expert consensus synthesis model, in order to tackle specific, important questions or ‘grey areas’. These Consensus Guidelines, which may be prepared jointly with other scientific societies, are intended to supplement the CPGs.

How does the incorporation of the ESMO-MCBS facilitate use of the CPGs?

The  ESMO Magnitude of Clinical Benefit Scale (ESMO-MCBS) is an objective, easy-to-use tool that quantitates and classifies the clinical benefit patients with solid tumours can expect to derive from a new treatment. Using overall and progression-free survival, quality of life and response rates as endpoints, the ESMO-MCBS grades the benefit of curative as well as palliative therapies. The scale can provide an answer to a question that preoccupies every physician (and patient) in their daily clinical practice, “What is the clinical significance and magnitude of the benefit of a new therapy?” – a question often not answered by statistical tests or regulatory approval of cancer therapies.

ESMO believes the MCBS has a place in every CPG.

MCBS scores have been calculated for all new cancer treatments approved since 1 January 2016. Within a CPG, MCBS scores appear with every recommendation relevant to the new therapy and again in a summary MCBS score table along with comparators, survival gains and toxicity profiles.

Do the changes make the guidelines easier to use in clinical practice?

Absolutely! The clinician, in addition to reading the guideline text, can now look up the management flow chart, the biomarker table, the recommended staging and work-up procedures, and the MCBS scores of all new approved therapies. The information can be accessed in a variety of different ways: the CPGs can be downloaded from the ESMO website and from  Annals of Oncology and abridged versions of the guidelines— the ESMO Pocket Guidelines—are available in print at congresses and as a  Library App for smartphones. We’ve also developed the eUpdate, a fast, flexible tool to communicate important breakthroughs or new MCBS scores. Summarising new evidence and formulating a new recommendation, eUpdates are produced whenever needed and are circulated in digital newsletters, and also appear on the  ESMO Clinical Practice Guidelines news webpage. In the future, we may consider developing an electronic platform allowing us to integrate eUpdates into the parent CPG in real-time, providing practising clinicians with a ‘living’ document.

Have you had any feedback from CPG users about the improved practice element?

I’m happy to say that feedback has been extremely positive and the changes have enhanced the uptake and visibility of the CPGs. For example, we have seen a substantial increase in requests from around the world for local adaptations of the guidelines and we are encouraged by the fantastic response to the recent  Pan-Asian adaptation of the metastatic colorectal cancer CPG. We are also receiving a huge number of webpage views of the CPGs, up from 90,000 five years ago to over one million per year. We are extremely happy with how the new practice-focused guidelines have been received and promise to keep looking to deliver guidelines in ways that help oncologists in their everyday work.

A more practical tool

Do you think that the ESMO CPGs are used widely in clinical practice?

Michalis Karamouzis

Michalis Karamouzis Medical School, National and Kapodistrian University of Athens, Greece

The result of a collaborative effort of experts in each of the tumour types, the ESMO CPGs are relevant to all practising clinicians, whether they be in a large specialist centre or a general hospital. In fact, the majority of oncologists worldwide are not specialists but will be treating patients across a variety of tumour types. This means they must try to assimilate the rapidly changing data becoming available across all of these areas and use it to make optimal treatment decisions on a daily basis, an almost impossible task. The popularity of the ESMO CPGs among clinicians reflects the way they combine a user-friendly, easy-to-read style with in-depth knowledge, providing a quick reference guide to evidence-based treatment and follow-up decisions. Their appeal is further enhanced by the fact that they’re continually being updated to reflect the latest findings in oncology. This means that all oncologists are able to have an up-to-the-minute guide for daily clinical practice.

The CPGs have definitely evolved into more of a practical tool.

Do the changes to the CPGs make it easier for doctors to apply them in clinical practice?

The increased practical usefulness of the CPGs is due mainly to the inclusion of more treatment algorithms and management suggestions that are needed in everyday clinical practice. Some of the currently available alternative guidelines provide scientific information but without management suggestions, and this can serve to confuse rather than to help oncologists. The new elements of the CPGs give all oncologists, irrespective of the country in which they practise, clear guidance about a number of different management alternatives and this helps them to be more secure in their treatment decisions. 

As a member of the ESMO Practising Oncologists Working Group, how do you think the enhanced guidelines support best practice at the point of care?

Oncologists usually face treatment dilemmas for many of their patients due to the overwhelming amount of data published and/or presented in many journals and congresses. ESMO is a very trusted organisation and oncologists already feel confident about the scientific content of the ESMO CPGs, which is based on latest knowledge and expert opinion. The new CPG features, particularly the treatment recommendation summaries and algorithms, give the busy practising oncologist fast access to the latest information, either in printed form, through the ESMO website or via the  App. I think that the restructuring of the content has increased the usefulness of the CPGs and will encourage more doctors worldwide to use them in their daily work-life.

Management options at a glance

Do you routinely use the ESMO CPGs when managing patients?

Fontecedro-Alessandra-Curioni

Alessandra Curioni Fontecedro University Hospital of Zurich, Switzerland

I think that for most practising oncologists, the ESMO CPGs are an essential part of clinical practice. This doesn’t mean that we always refer to them on a daily basis. When you’re regularly managing many patients a day with lung cancer, you’re combining your medical experience over all these different cases with your knowledge of the guidelines. However, the CPGs are the first place I go when I come across a more unusual tumour type, or when I’m facing particular side effects, such as those associated with immunotherapies, which need specific management approaches.

Do you think the enhanced practice element of the guidelines has made them easier to use?

Without a doubt, yes. The new features of the guidelines, namely the algorithms and the incorporation of the ESMO-MCBS scores, have increased the relevance of the CPGs for each particular treatment to be used or action to be taken. We know that the CPGs can be relied on to provide us with up-to-date, unbiased information.

The new elements mean that it is now easier for clinicians to see at a glance the various management options that are available to them.

I especially like the revised layout of the CPGs. They are much less wordy and instead present information in algorithms and tables. This means that clinicians don’t have to wade through a lot of text to find the section they’re interested in but can always go back to the text for the reference.

Will the enhanced practice elements change your use of the guidelines?

I discussed this question with various colleagues. Almost all the oncologists I work with already use the guidelines anyway. But we all came to the same conclusion, that because we can more quickly and easily find answers to management questions we may have, we are likely to consult the new CPGs more, even in less complex cases.

Great support for daily patient care

You are involved in guideline development for testicular cancer. How important do you think the practice element is?

oing-christoph

Christoph Oing University Medical Centre Eppendorf, Hamburg, Germany; ESMO Young Oncologists Committee Member

The practice element of the ESMO guidelines is crucial to achieving their goal of aiding decision making and guiding the treatment of cancer patients in daily practice across Europe and the rest of the world. The new structure makes the guidelines much easier to read and more convenient to use and the fact that the layout, including the consistent use of colouring to represent different treatment modalities in management flow charts, is standardised over CPGs really helps you to know where to look when you are searching for information across different tumour types. I first became involved with ESMO guideline activites when I took part in the ESMO Expert Consensus Conference on Testicular Cancer in November 2016 and it was a great experience. For challenging and rare clinical tumours, where there is generally little high-level evidence, consensus recommendations based on expert discussion are valuable complementary tools to evidence-based CPGs. 

Is there more focus or less focus on practice in the ESMO CPGs compared with other guidelines?

There is a mixture of guideline types available for oncologists, ranging from extensive to more practice-focused, concise recommendations. And there is a place for all the different types, depending on the question you are asking. Personally, I think that the ESMO CPGs are unique in managing to be both comprehensive and concise at the same time, making them particularly suitable for use in clinical practice.

The enhanced ESMO CPGs are a great support for daily routine patient care.

Do you think the improved practice element will make them more attractive to young oncologists? 

In the practice setting, it all comes down to time. While guidelines are an important source of knowledge, when you need an answer quickly, you often just don’t have enough time to read a lot of information. This is where the concisely formulated ESMO CPGs, with their easily understandable charts, may be more attractive to young oncologists. In Germany, we also have guidelines provided by the German Society for Haematology and Medical Oncology (DGHO) and I know that some of my colleagues will use these too. Me, I am a committed, regular user of the ESMO CPGs. The  ESMO Pocket Guidelines, the  App, the flow charts and the rapidly communicated electronic updates of practice-changing trial results provide an easy way of getting all the information I need to help me give patients the most up-to-date, professional care possible.

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