Finding evidence-based answers to practical questions in radiology: which patients with inoperable hepatocellular carcinoma will survive longer after transarterial chemoembolization?

To some, evidence-based practice (EBP) means the identification of centers that produce evidence reports and technology assessments to support guideline development. To others, EBP is the best research evidence integrated with clinical expertise and patient values. Inherent in the first approach is the implication that only central academic organizations can produce valid, reliable analyses of existing literature, which will then be distributed to ordinary practitioners. The second approach implies that ordinary practitioners can learn to use a stepwise approach and a preprepared set of rules and tools to effectively find the best current literature, appraise it, and then apply local circumstances to these rules and tools in their hospital. Paul Glasziou, director of the Centre for Evidence-based Practice in Oxford, England, has coined the phrases top-down EBP and bottom-up EBP to describe these approaches. In this article, the authors describe how knowledge gaps in an ordinary radiology practice can be addressed by using stepwise bottom-up EBP techniques. The following clinical scenario is used: Your hospital's recently appointed chief hepatobiliary surgeon questions the use of transarterial chemoembolization for inoperable hepatocellular carcinoma because of his concerns after reading a recent review article suggesting that there is no clear survival benefit to using this procedure. What would you do? Here is how the authors would do it.