military health system (i.e., those covered by CHAMPUS), men who had received radical prostatectomy before and after the guideline was published were asked in a survey to report whether or not they had been offered treatment options. The guideline was mailed to each practitioner within the system. The average number of treatments offered increased following publication of the guideline (Thompson et al., 1995). A limitation of this study is that it included only men undergoing radical prostatectomy, not all men with prostate cancer.

Evidence on The Impact of Guidelines in Canada and Europe

Canada. Adherence to breast cancer guidelines in British Columbia as assessed in 1991 was very high for radiation therapy, with 95 percent of women receiving radiation therapy following breast conserving surgery. However, only 77 percent of women received adjuvant chemotherapy when indicated, and 68 percent received tamoxifen when indicated (Olivotto, 1997). Adherence to guidelines was higher at cancer centers than among community oncologists. Improvements in disease-free and overall survival coincided with implementation of the guidelines, but other factors such as the regionalization of cancer care services and the presence of strong opinion leaders may account for good outcomes.

Italy. In an effort to improve community-based cancer care in Italy, guidelines on the treatment of breast, colorectal, and ovarian cancer were sent to practitioners in 1977. The effects of the educational program were evaluated in 1987 (Grilli et al., 1991). The familiarity of practitioners with the breast cancer guidelines was poor: roughly one-half knew of the breast cancer guideline, one-third knew of the colon cancer guidelines, and one-quarter knew of the ovarian cancer guidelines (estimates are weighted averages of respondents to a survey of providers). Compliance with the recommendations of the guidelines was poor in several areas as shown by chart audit. For women with breast cancer, for example, only 37 percent had full staging, and only 61 percent had a bilateral mammogram at the time of surgery (Table 6.8). Better compliance was observed among physicians with high-volume practices. The authors note that the results were "disappointing" and that efforts to improve cancer care with a "guidelines diffusion" approach appear to have had a negligible effect on cancer treatment.

France. Cancer care guidelines developed and disseminated through a regional cancer center in Lyon, France, appear to have succeeded in improving cancer care. Guidelines on breast and colon cancer were developed by a task force in 1993 and then reviewed by all practitioners in the region. In 1994, the guidelines were widely available via different media—paper, computer disk, and on-line at the cancer center. A comparison of randomly selected patients with breast and colon cancer treated in 1993 and 1995 showed marked improvements in care. From 1993 to 1995, adherence to the recommended overall treatment sequence increased from 19 to 54 percent for breast cancer and from 50 to 70 percent for colon cancer (Table 6.9). The guidelines were reviewed again in 1995 and disseminated to a wider network of hospitals and providers through continuing education meetings and mailed reminders to physicians. Compliance measured from 1994 to 1996 also improved (Ray-Coquard et al., 1998). The success of the guideline program was attributed in part to the local development of the guidelines, their wide dissemination, and

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