Annals of Oncology Advance Access originally published online on August 19, 2005
Annals of Oncology 2006 17(1):177-178; doi:10.1093/annonc/mdj006
© 2005 European Society for Medical Oncology
letter to the editor |
Quality of care in clinical oncology: from the dreamworld to the real world of outcome assessment
We read with great interest the recent article by Vardy and Tannock [1
] and the letter by Gorodokin and Novik [2] about the definition of the quality of care in oncology. Both of them deal with a controversial aspect of clinical practice, still undefined from either a methodological or a practical point of view. Three distinct issues are handled by Vardy and Tannock in their review:- (i) Is the right treatment being given?
- (ii) Is cancer treatment being done well?
- (iii) In addition to the disease, is the patient also being treated?
- (ii) Is cancer treatment being done well?
The letter by Gorodokin and Novik integrates this approach, and identifies the two main outcomes of a high-quality oncologic care in overall survival and quality of life.
The two papers define the bases of quality of care in oncology and all oncologists should review either their own work or the work in their departments on the basis of the recommendations of Vardy and Gorodokin. However, some questions merit being discussed in detail.
Survival and quality of life are nearly unanimously considered the main patient outcomes, and every effort should be made to increase the quality of both clinical research and clinical practice, in order to improve them as much as possible [3]. Nevertheless, it is often hard to define and assess quality of care on the basis of these main outcomes, and frequently we have to use surrogate end points to assess the quality of our work in daily clinical practice [4, 5]. It follows that on one hand the quality assessment based on the main patient outcomes is obvious from a speculative point of view, but on the other hand it remains an unsolved problem in daily clinical practice. Indeed, neither the results of clinical trials, nor the levels of evidence used to draw up clinical guidelines can often overcome the need to use surrogate end points of efficacy to support both definition and assessment of quality of care. An interesting review tried to assess the impact of clinical practice guidelines on the quality of cancer care. Unfortunately, the conclusions, although promising, remained inconclusive, as the use of surrogate outcomes of effectiveness to assess quality of care could not be avoided, and surrogate end points could not be related to the main clinical outcomes [6]. Likewise, in recent years a number of clinical trials have tried to conjugate the main patient outcomes with some different surrogate outcomes of efficacy, but the results remain controversial and inconclusive when they are transferred from clinical research to clinical practice [7, 8].
At this point, a question seems to remain unanswered: can we really consider quality of care assessment a topic of clinical practice in oncology, or conversely should it be considered a sort of tale, lacking in any relationship with the real dimension of clinical practice?
Although no definitive data can be obtained from literature, it is mandatory to overcome the constitutional limits of the evidence-based medicine and the fragmentariness of the different experiences in daily clinical practice, in order to reach a comprehensive dimension of outcome research. Such a challenge can represent an intriguing field of investigation for clinical research and clinical practice, and if clinical and outcome research will represent the main tools of intervention, a new era might commence for quality of care definition and assessment in clinical research and clinical practice [9].
1 Department of Oncology, City Hospital, Rimini; 2 Department of Internal Medicine, Arcispedale S. Anna, Ferrara, Italy
* E-mail: dtassinari{at}rimini.com
References
1. Vardy J, Tannock IF. Quality of cancer care. Ann Oncol 2004; 15: 1001–1006.
2. Gorodokin GI, Novic AA. Quality of cancer care. Ann Oncol 2005; 16: 991.
3. ASCO Special Article. Outcomes of cancer treatment for technology assessment and cancer treatment guidelines. J Clin Oncol 1996; 14: 671–679.
4. Tassinari D, Panzini I, Sartori S et al. Surrogate outcomes in quality of life research: where will we end up? J Clin Oncol 2003; 21: 1894–1895.
5. Tassinari D. Surrogate end points of quality of life assessment: have we really found what we are looking for? Health Qual Life Outcomes 2003; 1: 71.[CrossRef][Medline]
6. Smith TJ, Hillner BE. Ensuring quality cancer care by the use of clinical practice guidelines and critical pathways. J Clin Oncol 2001; 19: 2886–2897.
7. Buyse M, Thirion P, Carlon RW et al. Relation between tumour response to first-line chemotherapy and survival in advanced colorectal cancer: a meta-analysis. Lancet 2000; 356: 373–378.[CrossRef][Web of Science][Medline]
8. Shanafelt TD, Loprinzi CL, Marks R et al. Are chemotherapy response rate related to treatment-induced survival prolongations in patients with advanced cancer? J Clin Oncol 2004; 22: 1966–1974.
9. Lee SJ, Earle CC, Weeks JC. Outcome research in oncology: history, conceptual framework and trends in literature. J Natl Cancer Inst 2000; 92: 195–204.
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