plemented site-specific guidelines for staging, medical management, nursing, and rehabilitation. Community practice for breast, rectal, and small-cell lung cancer was evaluated in 1985-1986 after the program had been fully implemented. There was no evidence of diffusion of guideline principles to the majority of practicing physicians, even those who were involved in their development (Table 6.6).

Some CHOPs developed more intense programs to encourage compliance that included tumor boards, educational efforts, peer pressure, and administrative action. The CHOPs that were able to ensure staging did so by requiring completion of forms before specimens were submitted to pathology or denying privileges if forms were not completed. As the authors note, these measures were successful but did not require guidelines. The authors conclude that for clinical practice guidelines, ''leadership and organizational commitment appear to be the necessary ingredients.''

Even though the guidelines were developed locally, it is likely that the program failed to change provider behavior because there was no plan for implementation and no system to hold providers accountable for change (Katterhagen, 1996).

ASCO Guideline on Use of Hematopoietic Growth Factors. Hematopoietic growth factors are effective when administered to prevent or treat neutropenia (an abnormally small number of a type of blood cell), which may occur following chemotherapy, but they do not improve outcomes for those with febrile neutropenia (fever associated with neutropenia). The growth factors are expensive to use ($200 to $300 per dose), but there is little harm to patients if they are administered inappropriately. Their administration can be a significant source of income to a physician. Guidelines issued by ASCO in 1994 on the use of hematopoietic growth factors led to some reduction in their inappropriate use, but serious overuse of these substances persisted. This finding was based on physicians' self-reported use of hematopoietic growth factors on surveys conducted before, and shortly after, the 1994 guideline was issued and again following the publication of a guideline update in 1996. Response rates to the surveys were roughly 60 percent. Inappropriate