Gastrointestinal Unit, Department of Medical Oncology, Institut Jules Bordet - Université Libre de Bruxelles (ULB), Brussels, Belgium.
Department of Oncology, University of Turin, Turin, Italy.
Cancer Treat Rev. 2020 Jan;82:101930. doi: 10.1016/j.ctrv.2019.101930. Epub 2019 Nov 11.
While the management of nonmetastatic and oligometastatic rectal cancer has rapidly evolved over the last few decades, many grey areas and highly debated topics remain that foster significant variation in clinical practice. We aimed to identify controversial points and evidence gaps in this disease setting by systematically comparing recommendations from national and international clinical guidelines.
Twenty-six clinical questions reflecting practical challenges in the routine management of nonmetastatic and oligometastatic rectal cancer patients were selected. Recommendations from the ESMO, NCCN, JSCCR, Australian and Ontario guidelines were extrapolated and compared using a 4-tier classification system (i.e., identical/very similar, similar, slightly different, different). Overall agreement between guidelines (i.e., substantial/complete disagreement, partial disagreement, partial agreement, substantial/complete agreement) was assessed for each clinical question and compared against the highest level of available evidence by using the χ statistic test.
Guidelines were in substantial/complete agreement, partial agreement, partial disagreement, and substantial/complete disagreement for 8 (30.8%), 2 (7.7%), 7 (26.9%), and 9 (34.6%) clinical questions, respectively. High level of evidence supported clinical recommendations in 3/10 cases (30%) where guidelines were in agreement and in 10/16 cases (62.5%) where guidelines were in disagreement (χ = 2.6, p = 0.106). Agreement was frequently reached for questions regarding diagnosis, staging, and radiology/pathology pro-forma reporting, while disagreement characterised most of the treatment-related topics.
Substantial variation exists across clinical guidelines in the recommendations for the management of nonmetastatic and oligometastatic rectal cancer. This variation is only partly explained by the lack of supporting, high-level evidence.
在过去几十年中，非转移性和寡转移性直肠癌的治疗管理迅速发展，但仍存在许多灰色地带和极具争议的问题，导致临床实践存在显著差异。我们旨在通过系统比较国家和国际临床指南的建议来确定该疾病领域的争议点和证据空白。
选择了 26 个反映非转移性和寡转移性直肠癌患者常规管理实际挑战的临床问题。提取 ESMO、NCCN、JSCCR、澳大利亚和安大略指南的建议，并使用 4 级分类系统（即相同/非常相似、相似、略有不同、不同）进行比较。使用卡方检验评估每个临床问题指南之间的总体一致性（即实质性/完全不一致、部分不一致、部分一致、实质性/完全一致），并与可用的最高证据水平进行比较。
对于 8 个（30.8%）、2 个（7.7%）、7 个（26.9%）和 9 个（34.6%）临床问题，指南分别为实质性/完全一致、部分一致、部分不一致和实质性/完全不一致。在指南一致的 3/10 个病例（30%）和指南不一致的 10/16 个病例（62.5%）中，高等级证据支持临床建议（χ²=2.6，p=0.106）。在诊断、分期和影像学/病理学报告形式方面的问题上，通常会达成一致，而在治疗相关问题上，通常会存在分歧。
在非转移性和寡转移性直肠癌的治疗管理建议方面，临床指南之间存在很大差异。这种差异部分是由于缺乏支持性的高等级证据所导致。
