Before we close out colon cancer awareness month, I want to draw attention to another important paper in the journal Gastroenterology, “Understanding differences in the guidelines for colorectal cancer screening,” by Thomas Imperiale and David Ransohoff. (subscription required, published online March 16 ahead of print).
The authors start with the broad message that guideline-setting in general is of such concern that the Institute of Medicine has formed a committee “to develop standards (that) ensure that clinical practice guidelines are unbiased, scientifically valid and trustworthy.” They remind readers that:
“The problem of varying quality is highlighted by the fact that there are nearly 300 guidelines-making organizations that have created over 2300 guidelines in a process described as “essentially unregulated.”
But their focus was on colorectal cancer screening guidelines, and specifically different updates issued by two major guidelines organizations in 2008:
• The “multi-society” guidelines issued jointly by subspecialists in cancer prevention, gastroenterology and radiology.
• The US Preventive Services Task Force.
The authors focus on the first group’s “preference for tests that image the colon” – especially colonoscopy.
The authors say that the USPSTF, on the other hand, “considered several strategies to be similar in terms of years of life saved and reduction in colorectal-specific mortality,” including colonoscopy and less expensive blood stool tests. The USPSTF stated no preference among methods. But the USPSTF did not share the multi-society group’s endorsement of newer virtual colonoscopy and fecal DNA testing.
These are significant differences, according to the authors:
“The current differences in CRC screening guidelines raise practical questions not only about what doctors and patients should do in the face of disagreement, but also about the larger process by which guidelines are made and how “trustworthy” they may be.
Further, the potential for conflict of interest is real when subspecialists support or recommend procedures from which they derive income is real; that conflict should be acknowledged and managed rigorously. Conflict may be not only financial; it may also be intellectual, when professional enthusiasm causes one to favor what one has learned to do and knows best.”
I encourage journalists to find and read the full Imperiale/Ransohoff paper.
Gastroenterology. 2010 Mar 16. [Epub ahead of print]
Understanding differences in the guidelines for colorectal cancer
Imperiale TF, Ransohoff DF.
Division of Gastroenterology and Hepatology, Department of Medicine,
Indiana University School of Medicine, Indianapolis, IN; Regenstrief
Institute, Inc., Indianapolis, IN.
PMID: 20302867 [PubMed - as supplied by publisher]
And I encourage them to be aware of the Institute of Medicine’s review of guideline setting. Many “awareness month” campaigns are far too simplistic and incomplete and may, indeed, mislead consumers in the certainty they seem to convey. This is far from a certain field at this point in time.
Here are some recent posts raising important questions about what we know and don’t know about colon cancer screening: