Annals of Oncology Advance Access originally published online on February 6, 2006
Annals of Oncology 2006 17(4):691-701; doi:10.1093/annonc/mdl003
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© 2006 European Society for Medical Oncology
Quality of systematic reviews used in guidelines for oncology practice
1 Department of Biomedical Sciences and Human Oncology, University of Torino, Torino, Italy; 2 Department of Medical Sciences, Avogadro University, Novara, Italy; 3 Department of Epidemiology and Public Health, Imperial College, London, UK; 4 University of Modena and Reggio Emilia, Modena, Italy
* Correspondence to: Dr F. Vigna-Taglianti, Department of Medical Sciences, Avogadro University, Via Solaroli 17, 28100 Novara, Italy; Phone: +39-011-40188305; Fax: +39-011-40188301; E-mail: federica.vignataglianti{at}oed.piemonte.it
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Abstract |
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 Top Abstract introductionmethodsQUOROM-based checklistresultsdiscussiongeneral referenceslist of evaluated guidelineslist of reviews mentioned... |
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Background: Systematic reviews are an important tool for developing clinical recommendations. Those of high quality assure a good level of confidence on the strength of the recommendations.
Methods: A QUOROM-based checklist was applied to the reviews cited in a sample of guidelines on breast and colon cancer prevention and therapy. The checklist provided a weight for each criterion and a total quality score. Each review was independently evaluated by two reviewers; disagreements were solved by consensus.
Results: Eighty reviews (96%) were retrieved and evaluated; 36 focused on breast, and 44 on colorectal cancer. Twenty-three reviews (29%) did not match the definition of systematic review. In 17 (21%) the searching methods were unclear or described elsewhere. Forty (50%) were systematic. Not systematic, low and very low quality reviews accounted for 70% of the total. No review obtained the A+ class score; only 5 (6%) the A– and 7 (9%) the B+.
Conclusions: The results of this assessment provide a sober picture of the quality of the sources used to build guidelines. Oncologists should be aware that they could be relying on poor underlying documents. Writing groups should be aware of methodological problems, and should consult the existing manuals for the preparation of guidelines.
Key words: breast cancer, colorectal cancer, evidence-based medicine, guidelines, quality assessment, reviews
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introduction |
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TopAbstractintroductionmethodsQUOROM-based checklistresultsdiscussiongeneral referenceslist of evaluated guidelineslist of reviews mentioned... |
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Methods for grading clinical evidence and recommendations are a relatively new and important area of research. Systematic reviews and guidelines provide essential information for making well informed decisions. Implicitly or explicitly, reviewers and people who use reviews draw conclusions about the quality of evidence, and such judgments guide subsequent decisions.
Assessing the quality of evidence appears very important; however, until few years ago there was wide variation in the approaches used to grade evidence and recommendations by different organisations and all of these approaches had important shortcomings.
Systematic and explicit approaches help to protect against errors, resolve disagreements, facilitate critical appraisal, and communicate the conclusions. Agreement on methodological approaches for the evaluation of the evidence has been reached by the GRADE working group in 2004 [6
]; they developed a method to make sequential judgements about the quality of evidence for each important outcome, the overall quality of evidence across outcomes, and the recommendations. Some practical tools have been developed for assessing the quality of review articles [10, 11] and for evaluating the quality of reporting [8].
Our main objective was to assess the quality of the sources (reviews, systematic reviews and meta-analyses) used for the development of guidelines on prevention and treatment of breast and colorectal cancers.
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methods |
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TopAbstractintroductionmethodsQUOROM-based checklistresultsdiscussiongeneral referenceslist of evaluated guidelineslist of reviews mentioned... |
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Reviews and meta-analysis used for the development of guidelines on prevention and treatment of breast and colorectal cancers published between 1998 and 2003 have been identified, retrieved and evaluated using a quality checklist.
identification of guidelines
To identify the guidelines focused on prevention and treatment of cancers under study, the websites of some of the main international institutions involved with prevention and treatment of cancer were explored. The following websites were checked:
- NHMRC (National Health and Medical Research Council), Australia
- Cancer Care Ontario Practice Guidelines Initiative
- NCCN (National Comprehensive Cancer Network)
- SIGN (Scottish Intercollegiate Guidelines Network)
- ASCO (American Society of Clinical Oncology)
- ESMO (European Society for Medical Oncology)
- American College of Gastroenterology
- NCI (National Cancer Institute)
- Royal College of Surgeons of England; Association of Coloproctology of Great Britain and Ireland
- Royal College of Radiologists Clinical Oncology Information Network
- COR-CPO, Piedmont Region
From these websites, guidelines on primary prevention and treatment (including clinical follow-up of patients) of breast and colorectal cancer published from 1998 to 2003 were identified and downloaded. Secondary prevention was excluded. The search was performed between October and December 2003.
identification of reviews
Text and references of the retrieved guidelines were scanned to identify all possible reviews used as source of information for the elaboration of the recommendations, as well as other possible guidelines of interest. Reviews focused on adverse effects, treatment of complications, and quality of life were excluded.
Using a formal definition of systematic review (e.g. [4]), the number of papers meeting the definition should have been very small. For this reason we used a less strict definition to classify the retrieved papers: systematic reviews were considered all those performing a literature search at least on a electronic scientific database (e.g. Medline).
On this base, the reviews were classified as:
- Clearly systematic
- Doubtful (for unclear searching methods or because searching methods were described elsewhere)
- Not systematic
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QUOROM-based checklist |
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TopAbstractintroductionmethodsQUOROM-based checklistresultsdiscussiongeneral referenceslist of evaluated guidelineslist of reviews mentioned... |
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In order to assess the quality of the reviews, several checklists were examined: the Oxman-Guyatt index [11
], the QUOROM [8], that used by the New Zealand Guidelines Group [9] and that used by the Scottish Intercollegiate Guidelines Network [12]. Among these, the most validated are the Oxman- Guyatt index, consisting of 10 general criteria, and the QUOROM, consisting of 21 headings focused on the quality of reporting. The QUOROM was judged as the most comprehensive one, but to use it as a tool to evaluate the quality of the reviews, the following criteria were added to the original checklist:- Title: the identification of the study design and the intervention under study.
- Abstract: the description of results of the heterogeneity assessment (Cochrane Collaboration: [7]).
- Objectives: a clear description of the review's objectives, including intervention, comparison and outcome definitions [9, 12].
- Methods: the completeness of the bibliographic sources; the language exclusions; the update of the searching; the duplicate assessment for the selection procedure, the quality assessment and the data abstraction [11, 12]; the inclusion of allocation concealment, blinding, attrition and ITT (intention-to-treat analysis) among the criteria for assessing the quality of the trials. For non randomised studies, a similar list was developed, containing description of population base, attrition, and control for confounding variables.
- Results: in the ‘studies characteristics’ section a list of the outcomes measured by each included study; a list of excluded studies and the reasons for the exclusion [3]. Subgroup analysis, results of the heterogeneity assessment, assurance of homogeneity in combining studies in the meta-analysis were also considered as quality criteria [11, 12]. Formal evaluation of publication bias is very rare, so that a clear description of the results (providing funnel plot or the findings of other methods) was added as a quality criterion [3].
- Discussion: recommendations for practice.
The comparison between the original QUOROM checklist and the modified version is available on request.
quality scores
The QUOROM-based checklist (Table 1) provides a value for each quality criterion whose total score is 50.
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A score was assigned if a specific criterion was completely satisfied; for the title, abstract, introduction and objectives sections a score was given only if the information was described in the specific section. As regards methods and results, the procedure was less strict: the score was given also when the information was not in the proper section, but was provided somewhere.
For the search strategy, a score was given if at least the keywords used to retrieve the papers were provided.
For the quality assessment additional criteria, the score was attributed if the review used at least three of the four mentioned criteria in the methods section.
Sensitivity analysis was considered as the analysis performed with and without low quality studies; all the others were considered as subgroup analyses.
The QUOROM-based checklist is fully presented in Table 1.
Four quality classes were created, based on the completion of the total score (A, B, C, D); each class was further divided into two (+ and –). Therefore, according to the scores, seven classes were finally created: A+: 46–50; A–:41–45; B+: 36–40; B–: 31–35; C+: 26–30; C–: 21–25; D: 0–20.
Such categories can be referred to the definitions developed by the GRADE working group [6].
- High (A+, A–): Further research is very unlikely to change our confidence in the estimate of effect.
- Moderate (B+, B–): Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
- Low (C+, C–): Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
- Very low (D): Any estimate of effect is very uncertain.
quality assessment
Each systematic review was independently evaluated by two reviewers, using the QUOROM-based checklist. Disagreements were solved by consensus.
The findings were analysed in order to obtain summary results. Only the summary of the assessment is provided in this report; however, the result of each assessment is available on request.
Based on the quality of the reviews cited by each Guideline, a general evaluation of the source of evidence used to build practice recommendations was given.
Lastly, recommendations were elaborated for the improvement of systematic reviews and the guidelines development.
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results |
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The flow of articles evaluated through the exercise is shown in Figure 1.
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guidelines
Out of 128 guidelines published between 1998 and 2003 and identified by the search, 59 guidelines focused on primary prevention and treatment of breast (n = 33) and colon cancer (n = 23) or on both cancer sites (n = 3) were downloaded and examined (Guidelines: [GL1–59]) (Table 2). As regards year of publication, four (6.8%) were published in 1998, five (8.5%) in 1999, seven (11.9%) in 2000, 12 (20.3%) in 2001, 11 (18.6%) in 2002, and 20 (33.9%) in 2003.
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reviews cited in the guidelines
Overall, 171 reviews were cited by the 59 guidelines. Out of the 83 reviews focused on breast and colon cancer prevention or treatment, 80 (96.4%) were retrieved and evaluated (breast cancer n = 36, colorectal cancer n = 44); three reviews [R15
, R53, R75] were not available in the network of libraries we contacted and therefore they did not enter the assessment process. The classification of the cited reviews for breast, colon and both cancers is presented in tables 3, 4 and 5.
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Some guidelines did not cite any review in bibliography: for breast cancer, 2 out of 33 (6.0%) and for colorectal cancer 9 out of 23 (40%). Considering also the guidelines citing only one review, the percentages increase respectively to 24% for breast cancer and 48% for colorectal cancer.
assessment of reviews
Out of the 80 retrieved and evaluated reviews, 23 (28.7%) did not match the definition of systematic reviews, and were not evaluated with the checklist (Table 6). It was not possible to classify 17 reviews: 7 (8.7%) because the searching methods were described elsewhere, 10 (12.5%) because the searching methods were unclear. Only forty reviews (50%) were clearly systematic.
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No reviews reached the A+ class score (46–50), and only five (6.2%) reached the A– class (41–45); 7 (8.7%) obtained the score of the B+ class (36–40). The figures for A– and B+ class were two (5.5%) and five (13.9%) for breast cancer and three (6.8%) and 14 (31.8%) for colorectal cancer respectively. Non-systematic, low (C class) and very low (D class) quality reviews accounted for 70% of the total, respectively for 80.6% of the breast cancer reviews and 61.4% of the colorectal cancer reviews.
Overall the 57 systematic reviews reached about 60% of the total score, with a mean score of 29.9 (C+ class). The sections most affected by low scores are: methods (average score: 6.8/15.0, only 45.6% of the standard score) and results (average score: 6.9/13.0, 53.1% of the standard). Analysing the specific chapters within the sections, the ‘quality assessment’ in the methods section was the most affected one (average percentage of the score 26.8), but also searching and quantitative data synthesis showed low scores (respectively, 40.6% and 52.9% of the standard).
Some interesting differences among the quality classes can be pointed out. Quantitative data synthesis in the results section appear to have low scores without distinction between quality classes: also the A– class reaches only 67.5% of the standard. Title and studies characteristics appear to be affected by a low score only in C– and D classes. Discussion section presents very low scores only in the very low quality class (D class, 51.4% of the score reached), whilst abstract, searching, selection, quality assessment and quantitative data synthesis in the methods section obtained low scores in C+, C– and D classes. Quality assessment presents very low scores in all the classes except for A– and B+.
The specific scores obtained by each breast and colon cancer reviews are available on request.
quality of guidelines
The percentage of clearly systematic reviews within a guideline accounted for a variable percentage, between 0% and 100% for breast cancer, and between 0% and 86% for colon cancer (Table 3, 4 and 5).
A very low percentage of the total guidelines use systematic reviews of high quality as source of evidence. Only 10 out of 33 breast cancer guidelines (30.3%) [GL7, GL8, GL10, GL19, GL32, GL33, GL41, GL46, GL56, and GL57] and only 6 out of 23 colorectal cancer guidelines (26.1%) [GL11, GL18, GL21, Gl22, GL48, and GL52] cited in bibliography at least one review of good quality (A or B quality classes).
Among the guidelines on breast cancer, 7 (21.2%) use as source of information only not systematic reviews or no review at all, whilst for colorectal cancer, this figure is 12 (52.1%).
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discussion |
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TopAbstractintroductionmethodsQUOROM-based checklistresultsdiscussiongeneral referenceslist of evaluated guidelineslist of reviews mentioned... |
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The results of our assessment provide a sober picture of the overall quality of the sources used to write recommendations. Our score system provided 4 quality categories (A, B, C, D) which can be further divided (A+, A–, B+, B–, C+, C–, D). As described in the method section, such categories can be interpreted according to the definitions developed by the GRADE working group [6
]. A sample of recommendations (and the corresponding reviews on which they were based) was identified through a wide literature search including the most relevant entities involved in the preparation of the guidelines on primary prevention and treatment of breast and colon cancer, issued since 1998 to 2003. We have made no selection, so we have evaluated a recent and reliable sample based on the main international institutions. The assessment has been performed using a QUORUM-based checklist, modified adding specific quality criteria, and adopting a choice of scores following methodological considerations. On a total of 80 reviews, non-systematic, low and very low quality reviews accounted for 70% of the total. No reviews reached the A+ class (score 46–50), and only five (6.2%) reached the A– class (41–45); seven (8.7%) obtained the score of the B+ class (36–40). It is worth noting that the most affected section is the methods section: on average the mean score reached is 6.8 out of 15.0, only 45.6% of the standard score.
Only 30.3% of breast cancer and 26.1% of colorectal cancer guidelines used at least one high quality review, and the percentage of guidelines using only no systematic reviews is 21.2 for breast cancer and 52.1 for colorectal cancer.
These results are not totally new, as the problem has already been raised by others before. In particular, in one study the Appraisal of Guidelines and Research and Evaluation (AGREE) Instrument was used to assess the quality of 100 guidelines (including 32 oncology guidelines) from 13 countries [2]. Curiously, this study showed that oncology guidelines had significantly higher scores on rigor of development than non-oncology guidelines (42.2% versus 29.4%; P = 0.02). In particular, systematic methods to search for evidence were more often used (P = 0.01); the methods for formulating the recommendations were more clearly described (P = 0.02); and health benefits, risks, and side effects were more often considered in formulating the recommendations (P = 0.03). The authors concluded that the quality of practice guidelines is modest in general, but for certain domains, oncology guidelines seem to be of better quality than others. This study, as well as other similar works [5], do not take in consideration the specific aspect of the quality of the supporting evidence, which however appear to be of high relevance.
The main lessons that can be drawn from this exercise are:
- The quality of a guideline is determined by the quality of the base of evidence, and not only by the rigour of its development; some organisations producing guidelines developed specific tools for the quality assessment of the included reviews; however, none of the guidelines included in our sample detailed the results of such evaluation.
- When using recommendations oncologists should be aware that they could be based on poor underlying documents, i.e. their credibility could be undermined by lack of methodological rigour.
- When writing recommendations, writing groups should be aware of all the methodological problems involved, and are warmly invited to consult existing manuals for the preparation of practice guidelines (e.g. [9, 12]).
- The quality of reviews, particularly when preparing new guidelines or updating old ones, should be judged by using tools such QUOROM-based tools (Table 1).
Whether the results of the current evaluation have a mainly theoretical interest or impact on oncology practice it is not clear yet, but we propend for the second choice. Although ‘there is a tendency toward support for the idea that outcomes improve for patients, personnel, or organizations if clinical practice in health care is evidence-based, that is, if evidence-based clinical practice guidelines are used’ [1], however, the impact of guideline quality is less documented.
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Acknowledgements |
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This paper was made possible by a grant of the Ministry of Education, University and Research (grant number 2002061749 COFIN 2002) and a grant of the Compagnia di San Paolo (‘Qualità dell'assistenza oncologica’). All authors are independent from funders. We thank Federica Mathis for her contribution to the duplicate assessment of the reviews.
Received for publication August 30, 2005. Revision received December 20, 2005. Accepted for publication December 22, 2005.
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general references |
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6. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 1490–1497.
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8. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet 1999; 354(9193): 1896–1900.[CrossRef][Web of Science][Medline]
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list of evaluated guidelines |
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TopAbstractintroductionmethodsQUOROM-based checklistresultsdiscussiongeneral referenceslist of evaluated guidelineslist of reviews mentioned... |
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GL1. Bast RC, Ravdin P, Hayes DF et al. 2000 update of Recommendations for the use of tumor markers in breast and colorectal cancer: Clinical Practice Guidelines of the American Society of Clinical Oncology. J Clin Oncol 2001; 19(6): 1865–1878.
GL2. Benson AB 3rd, Desch CE, Flynn PJ et al. 2000 update of American Society of Clinical Oncology colorectal cancer surveillance guidelines. J Clin Oncol 2000; 18(20): 3586–3588.
GL3. Bond JH. Polyp Guideline: diagnosis, treatment and surveillance for patients with colorectal polyps. Am J Gastroenterol 2000; 95: 3053–3063.[CrossRef][Web of Science][Medline]
GL4. Breast Cancer Disease Site Group. Adjuvant systemic therapy for node-negative breast cancer. Practice Guidelines Report #1–8. 2003.
GL5. Breast Cancer Disease Site Group. Breast irradiation in women with early stage invasive breast cancer following breast conserving surgery. Practice Guidelines Report #1–2. 2003.
GL6. Breast Cancer Disease Site Group. Management of ductal carcinoma in situ of the breast. Practice Guidelines Report #1–10. 2002.
GL7. Breast Cancer Disease Site Group. The role of aromatase inhibitors in the treatment of postmenopausal women with metastatic breast cancer. Practice Guidelines Report #1–5. 2003.
GL8. Breast Cancer Disease Site Group. Surgical management of early-stage invasive breast cancer. Practice Guidelines Report #1–1. 2003.
GL9. Cantin J, Scarth H, Levine M, Hugi M, for the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the care and treatment of breast cancer: 13. Sentinel lymph node biopsy. Canada Medical Association Journal 2001; 165(2): 166–173.
GL10. Commissione Oncologia Regionale – Centro di Riferimento per l'Epidemiologia e la Prevenzione Oncologica in Piemonte. Tumore della Mammella. Linee Guida Organizzative per la Regione Piemonte. 2002.
GL11. Commissione Oncologia Regionale – Centro di Riferimento per l'Epidemiologia e la Prevenzione Oncologica in Piemonte. Tumori del colon-retto. Linee Guida Organizzative per la Regione Piemonte. 2001.
GL12. Emery C, Gallagher R, Hugi M, Levine M, for the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the care and treatment of breast cancer: 10. The management of chronic pain in patients with breast cancer (2001 update). Practice Guidelines Initiative – A Cancer Care Ontario Program. 2001.
GL13. ESMO Guidelines Task Force. Minimum clinical recommendations for diagnosis, adjuvant treatment and follow-up of colon cancer. 2002.
GL14. ESMO Guidelines Task Force. Minimum clinical recommendations for diagnosis, adjuvant treatment and follow-up of primary breast cancer. 2002.
GL15. ESMO Guidelines Task Force. Minimum clinical recommendations for diagnosis, treatment and follow-up of advanced colorectal cancer. 2002.
GL16. ESMO Guidelines Task Force. Minimum clinical recommendations for diagnosis, treatment and follow-up of rectal cancer. 2002.
GL17. Figueredo A, Rumble RB, Maroun J et al. Follow-up of patients with curatively resected colorectal cancer. Practice Guidelines Report #2–9. 2003.
GL18. Figueredo A, Zuraw L, Wong RKS et al. The use of preoperative radiotherapy in the management of patients with clinically resectable rectal cancer. Practice Guidelines Report #2–13. 2003.
GL19. Findlay BP, Walker-Dilks C, Pritchard K, and members of the Breast Cancer Disease Site Goup and the Systemic Treatment Disease Site Group. Epirubicin, as a single agent or in combination for metastatic breast cancer. Practice Guidelines Report #1–6. 2002.
GL20. Gastrointestinal Cancer Disease Site Group. Adjuvant therapy for stage II colon cancer following complete resection. Practice Guidelines Report #2–1. 2000.
GL21. Gastrointestinal Cancer Disease Site Group. Adjuvant therapy for stage III colon cancer following complete resection. Practice Guidelines Report #2–2. 2000.
GL22. Gastrointestinal Cancer Disease Site Group. Postoperative adjuvant radiotherapy and/or chemotherapy for resected stage II or III rectal cancer. Practice Guidelines Report #2–3. 1998.
GL23. Gastrointestinal Cancer Disease Site Group. Use of irinotecan (Camptosar, CPT-11) combined with 5-fluorouracil and leucovorin (5FU/LV) as first-line therapy for metastatic colorectal cancer. Practice Guidelines Report #2–16b. 2003.
GL24. Gastrointestinal Cancer Disease Site Group. Use of irinotecan in the treatment of metastatic colorectal cancer. Practice Guidelines Report #2–16. 2000.
GL25. Gastrointestinal Cancer Disease Site Group. Use of raltitrexed (tomudex) in the management of metastatic colorectal cancer. Practice Guidelines Report #2–17. 2002.
GL26. Harris S, Hugi MR, Olivotto IA, Levine M, for the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema. Canada Medical Association Journal 2001; 164(2): 191–199.
GL27. Hillner BE, Ingle JN, Berenson JR et al. American Society of Clinical Oncology guideline on the role of biphosphonates in breast cancer. American Society of Clinical Oncology Biphosphonates Expert Panel. J Clin Oncol 2000; 18: 1378–1391.
GL28. Levine M, Moutquin JM, Walton R, Feightner. Chemoprevention of breast cancer. A joint guideline from the Canadian Task Force on Preventive Health Care and the Canadian Breast Cancer Initiative's Steering Commitee on Clinical Practice Guidelines for the Care and the Treatment of Breast Cancer. Canada Medical Association Journal 2001; 164(12): 1681–1690.
GL29. Levine M, Sawka C, Bowman DM, for the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the care and treatment of breast cancer: 8. Adjuvant systemic therapy for women with node-positive breast cancer (2001 update). Practice Guidelines Initiative – A Cancer Care Ontario Program. 2001.
GL30. National Breast Cancer Centre. Psychosocial clinical practice guidelines: providing information, support and counselling for women with breast cancer. Canberra, Commonwealth of Australia. 1999.
GL31. National Health and Medical Research Council. Clinical practice guidelines: the prevention, early detection and management of colorectal cancer. Canberra, Commonwealth of Australia. 1999.
GL32. National Health and Medical Research Council Breast Cancer Centre. Clinical practice guidelines for the management of advanced breast cancer. 2001.
GL33. National Health and Medical Research Council Breast Cancer Centre. Clinical practice guidelines for the management of early breast cancer: second edition. 1999.
GL34. National Health and Medical Research Council Breast Cancer Centre. Clinical practice guidelines for the psychosocial care of adults with cancer. 2003.
GL35. NCCN – National Comprehensive Cancer Network. Practice Guidelines in Oncology: Breast Cancer. 2003.
GL36. NCCN – National Comprehensive Cancer Network. Practice Guidelines in Oncology: Breast Cancer Risk Reduction. 2003.
GL37. NCCN – National Comprehensive Cancer Network. Practice Guidelines in Oncology: Colon Cancer. 2003.
GL38. NCCN – National Comprehensive Cancer Network. Practice Guidelines in Oncology: Colorectal Screening. 2003.
GL39. NCCN – National Comprehensive Cancer Network. Practice Guidelines in Oncology: Genetic/Familial High-Risk Assessment: Breast and Ovarian. 2003.
GL40. NCCN – National Comprehensive Cancer Network. Practice Guidelines in Oncology: Rectal Cancer. 2003.
GL41. NCI – National Cancer Institute. Breast Cancer – (PDQ) – Treatment – Health Professionals. Guidelines. 2003.
GL42. NCI – National Cancer Institute. Colon Cancer – (PDQ) – Treatment – Health Professionals. Guidelines. 2003.
GL43. NCI – National Cancer Institute. Rectal Cancer – (PDQ) – Treatment – Health Professionals. Guidelines. 2003.
GL44. Olivotto IA, Levine M, for the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the care and treatment of breast cancer: 5. Management of ductal carcinoma in situ (DCIS) (2001 update). Practice Guidelines Initiative – A Cancer Care Ontario Program. 2001.
GL45. Pritchard KI, Khan H, Levine M, for the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the care and treatment of breast cancer: 14. The role of hormone replacement therapy in women with a previous diagnosis of breast cancer. Canada Medical Association Journal 2002; 166(8): 1017–1022.
GL46. Recht A, Edge SB, Solin LJ et al. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol 2001; 19: 1539–1569.
GL47. Royal College of Radiologists' Clinical Oncology Information Network. Guidelines on the non-surgical management of breast cancer. Clin Oncol 1999; 11: S89–S131.[CrossRef]
GL48. Royal College of Surgeons and Associates of Coloproctology of Great Britain and Ireland. Guidelines for the management of Colorectal Cancer. Royal College of Surgeons of England 2001.
GL49. Scarth H, Cantin J, Levine M, for the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the care and treatment of breast cancer: 3. Mastectomy or lumpectomy? The choice of operation for clinical stages I and II breast cancer (2002 update). Practice Guidelines Initiative – A Cancer Care Ontario Program. 2001.
GL50. SIGN – Scottish Intercollegiate Guidelines Network. Breast cancer in women. A National Clinical Guideline. Edinburgh – SIGN Publication No. 29. 1998.
GL51. SIGN – Scottish Intercollegiate Guidelines Network. Control of pain in patient with cancer. 2000.
GL52. SIGN – Scottish Intercollegiate Guidelines Network in collaboration with the Scottish Cancer Therapy Network. Management of colorectal cancer. A National Clinical Guideline. 2003.
GL53. Smith TJ, Davidson NE, Schapira DV et al. American Society of Clinical Oncology 1998 update of recommended breast cancer surveillance guidelines. J Clin Oncol 1999; 17(3): 1080–1082.
GL54. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the care and treatment of breast cancer: 9. Follow-up after treatment for breast cancer. Canada Medical Association Journal 1998; 158 (Suppl 3): S65–S70.
GL55. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Canadian Association of Radiation Oncologists. Axillary dissection. Canada Medical Association Journal 1998; 158 (suppl 3): S22–S26.
GL56. Verma S, Trudeau M, Pritchard K, Oliver T, and members of the Breast Cancer Disease Site Group. The role of taxanes in the management of metastatic breast cancer. Practice Guidelines Report #1–3. 2003.
GL57. Warr D, Johnston M, and members of the Breast Cancer Disease Site Group. Use of biphosphonates in women with breast cancer. Practice Guidelines Report #1–11. 2002.
GL58. Whelan T, Olivotto I, Levine M, for the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the care and treatment of breast cancer: 6. Breast radiotherapy after breast-conserving surgery (2003 update). Practice Guidelines Initiative – A Cancer Care Ontario Program. 2002.
GL59. Winawer SJ, Fletcher RH, Miller L et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 2003; 124: 544–560.[CrossRef][Web of Science][Medline]
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list of reviews mentioned in the evaluated guidelines |
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