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Mark Levine, Jean-Marie Moutquin, Ruth Walton, and John Feightner
Chemoprevention of breast cancer: A joint guideline from the Canadian Task Force on Preventive Health Care and the Canadian Breast Cancer Initiative's Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer
CMAJ 2001; 164: 1681-1690 [Abstract] [Full text] [PDF]
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[Read eLetter] Clinicians need concise, practical guidelines, not convoluted ones
John Sehmer   (22 June 2001)

Clinicians need concise, practical guidelines, not convoluted ones 22 June 2001
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John Sehmer

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Re: Clinicians need concise, practical guidelines, not convoluted ones

jsehmer{at}yahoo.com John Sehmer

June 20, 2001

Editor
Canadian Medical Association Journal
1867 Alta Vista Drive
Ottawa, ON
K1G 3Y6

Dear Sir/Madam,

After reading the latest in the CMAJ’s series of clinical practice guidelines for the diagnosis and management of breast cancer, I feel compelled to vent my frustration at yet another verbose, convoluted, and impractical guideline for those of us in clinical practice to follow.

Similarly, Appendix 2 the “Questions and answers on chemoprevention and breast cancer: A guide for women and their physicians” really seems totally impractical. The woman and her physician are asked to obtain the “Gail Index” from the website and answer the attached questions but to realize this should only be useful in “whether to further discuss the benefits and harms of taking tamoxifen”. A woman is supposed to decide whether she feels “a tamoxifen-induced stroke would be far worse than breast cancer” and decide against tamoxifen or if she would feel “that breast cancer would be far worse than a stroke” and decide to take tamoxifen. “You will have to determine the value you place on the possible consequences of taking or not taking tamoxifen after a full discussion with your doctor.” Once again, like so many other CMAJ consensus guidelines, this provides little assistance in the decision-making process for the physician or the patient. Am I supposed to ask my patient if they would prefer to die of breast cancer or a tamoxifen-induced stroke?

Both physicians and patients need help in making clinical decisions particularly when considering preventative treatments. Consensus documents would be extremely helpful if they were practical.

I would like to suggest the following. A consensus document should be no more than four or five pages long and concise in its recommendations rather than obfuscating around areas that are unclear. If the document is vague and indecisive, it should not be published.

It is stated that they have been “peer reviewed”. I am not sure who the peers are who review these documents; sometimes I wonder, due to the indecisiveness, if they have been edited by a lawyer rather then a clinician.

Peers should include clinicians and community practitioners. If the guideline document is unclear, ambiguous, or unhelpful it should be sent back to the authors for review.

Consensus documents and clinical guidelines are a great idea. They are needed. Please keep publishing them but always consider if the recommendations are clear, useful, and practical. Gratuitous statements such as “should only be used where the potential benefits outweigh the risks” are not helpful when the potential risks and benefits have not been outlined clearly in the document.

Yours sincerely,

John Sehmer

Reference
Chemoprevention of breast cancer: A joint guideline from the Canadian Task Force of Preventative Health Care and the Canadian Breast Cancer Initiative’s Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. CMAJ 2001; 164 (12): 1681-90