Treatment Guidelines

How Long Does It Take for New Guidelines to Trickle Down to Community Practice?

Treatment standards in oncology are constantly evolving, with new agents and treatment regimens added each year. Clinical practice guidelines often represent the cutting edge of treatment, identifying which new treatment approaches should become standard of care on the basis of careful data analysis and expert review. Unfortunately, these guidelines are often slow to be incorporated into community practice. Current estimates indicate that from the time a guideline is adopted to the time it is incorporated as a regular part of community practice can be as long as 7 years.

The delay in incorporating new guidelines into practice is due to numerous factors, chief of which include awareness and acceptance of the new recommendations. One of the principle reasons a guideline is not always immediately adopted is that physicians are not aware of the data supporting the recommendations, and therefore do not agree with them. It takes time for community practitioners to become familiar with data supporting novel treatment strategies, to understand these data, and to accept the change in practice. In many cases, community practitioners wait for the advice or opinions of trusted experts in their field before adopting new treatment approaches. A major step in incorporating new guidelines into practice is listening to experts review and explain the new data supporting a guideline. Hearing a trusted expert explain a guideline recommendation and the data supporting it and provide guidance on how best to incorporate this recommendation into clinical practice is a key step in adopting the guideline into clinical practice. In a survey of oncologists and hematologists in the prIME Oncology network, the opinions of nationally and internationally recognized experts was rated as one of the most influential sources of information about clinical advances.

Beyond awareness and acceptance of these new guidelines, there are often numerous barriers to implementation of a new treatment strategy that slow uptake. For example, a guideline-recommended treatment may not yet be approved by the local regulatory body, making access a challenge. Furthermore, a novel treatment may require a specific diagnostic test that is not widely available, that is logistically challenging, or that is cost prohibitive. Cost can be a major influencing factor when determining whether to follow a guideline-recommended approach, especially in the modern oncology setting, where challenges in reimbursement can have a major impact on treatment selection. Finally, community oncologists are frequently limited in their treatment choice by institutional pathways and formulary availability. If changes to a treatment guideline are not reflected in an institution’s pathway, or the recommended agents are not available in the institution’s pharmacy, the physician may have no choice but to ignore the guideline.

While treatment guidelines provide an outline for best practices in patient care, they are not always reflective of current community practice. A number of factors contribute to slow the adoption of treatment guidelines at the community level, from the physician’s own attitudes and beliefs to legal, financial, and institutional barriers. As new treatment guidelines emerge, better strategies—including education of the physician and hospital administration—are necessary to help speed the adoption of these guidelines.