What are the “domestic and international guidelines” that doctors often refer to? How do they work?

What is a “guide”? How did it come about?

Many patients, when talking to their physicians, are told, “According to the current international (national) guidelines, we should ……..”. . What are the “guidelines”? Why should doctors “follow” guidelines? This starts with the concept of “evidence-based medicine.

Evidence-based medicine (EBM) is a Western concept that, as the name implies, is “evidence-based medicine”. The core idea is that doctors base their decisions on the best available clinical research evidence, combined with personal expertise and clinical experience as appropriate. In layman’s terms, doctors should “follow the evidence” rather than “follow their feelings”. The guidelines (known professionally as clinical practice guidelines) are a compilation, evaluation, and summary of the “best current research evidence and expert experience.

Guidelines are usually written by expert committees of professional medical groups and are updated regularly as new research evidence becomes available, usually once or more per year. The “newer” the guideline, the more recent the clinical evidence used, and the more it reflects the most recently developed and professionally accepted treatment options. It is a guide and a “guideline” for physicians to use in the treatment of disease, so that the treatment of different hospitals and physicians is standardized and “conversational” rather than arbitrary.

What are the most commonly used guidelines for lung cancer?

Chinese guidelines

The Chinese Society of Clinical Oncology (CSCO) first published the CSCO Guidelines for the Management of Primary Lung Cancer in 2016, and revised and updated them in 2017. It provides recommendations for the diagnosis and treatment of non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) at all stages.

It is the most appropriate guideline for patients in China, with all recommendations divided into “basic strategies” and “optional strategies”. This has been adapted to take into account the differences in economic development, health insurance reimbursement, and medical resources in different regions of China, and has greatly improved the usefulness of the guideline.

“Basic strategies” are the most basic diagnostic and treatment options that balance reliable research evidence and access to resources, and are geared toward regions with relatively few health care resources; “optional strategies” are more “advanced” options. The “optional strategy” is a more “advanced” option that can be used in some areas of greater health care abundance.

Another feature of this guide is that the main content is presented in tables, at a glance, with a modest amount of text to supplement the explanations. For more in-depth information, you can follow the “References” at the end to find relevant research papers.

For patients and families with lung cancer in China, this guide can be a handy reference to help you better understand your doctor’s thinking, ask reasonable questions and make reasonable decisions with your doctor.

The 2016 edition of the CSCO Guidelines for the Management of Primary Lung Cancer (http://www.csco.org.cn/cat/148/topic/2368.html) is currently available for free on the official CSCO website. Updated versions can be downloaded by searching the Internet.

European Guidelines

The European Society for Medical Oncology (ESMO) has also developed a series of guidelines for lung cancer, including Early and Locally Advanced (Non-Metastatic) Non-Small Cell Lung Cancer: Diagnosis, Treatment, and Follow-up, ESMO Clinical Practice Guidelines (2017), Metastatic Non-Small Cell Lung Cancer: ESMO Clinical Practice Guideline (2016), ESMO Consensus Guideline: Locally Progressive Stage III Non-Small Cell Lung Cancer (2015), ESMO Consensus Guideline: Pathology and Molecular Biomarkers in Non-Small Cell Lung Cancer (2014), ESMO Consensus Guideline: First-, Second-, and Post-Line Treatment of Advanced Non-Small Cell Lung Cancer (2014), ESMO Consensus Guideline. Diagnosis, Treatment, and Follow-up of Early-Stage Non-Small Cell Lung Cancer (2014), and others.

The ESMO guidelines are text-based, with recommendations at the end of each paragraph guided by a “recommendation” and summarized in a “big table”. In more recent versions, concise flow charts have been added to facilitate physician reference for treatment pathways. The ESMO guidelines were one of the more widely used guidelines among Chinese physicians before the advent of the CSCO guidelines.

For patients and families, the ESMO guidelines are a good reference to get the “big picture” of the disease and to understand the right treatment concepts and approaches. The English versions of these guidelines can be found and downloaded for free from the official ESMO website (http://www.esmo.org/Guidelines/Lung-and-Chest-Tumours), but there is currently no officially recognized Chinese version.

U.S. guidelines

The National Comprehensive Cancer Network’s (NCCN) series of cancer guidelines are more “radical” guidelines. This is true in two ways. One is that they are updated quickly, several times a year. The latest version of the NCCN Non-Small Cell Lung Cancer Guidelines (dated April 26) is the fourth edition since 2018; the second is the speed of incorporating new research findings into the guidelines, which is why the NCCN guidelines are updated several times a year. As soon as important findings are published in a specialty area, the NCCN guideline panel discusses and may adjust guideline recommendations accordingly, often before the U.S. Food and Drug Administration (FDA) has responded, the NCCN guidelines have already revised their recommendations.

But this inevitably has some drawbacks.

First, there are inevitably “over-indication” recommendations, meaning that the guideline recommends a drug for more than the FDA-approved indication for the drug.

In addition, in other cancer NCCN guidelines, there have been cases where a recommendation made in one version of the guideline was removed in the next version of the guideline because of new studies that showed contrary results.

For patients and families, NCCN guidelines can provide the latest diagnostic and/or treatment ideas, but it is important to talk to your doctor about whether and how these “fresh” findings and recommendations can be used in your own treatment.

The NCCN Guidelines for Non-Small Cell Lung Cancer (https://www.nccn.org/professionals/physician_gls/default.aspx#site) can also be downloaded for free by registering on the NCCN website. The official Chinese version can also be found, but because the translation is from the 2015 edition, some of the content is older.

Which guide is best to use?

While each of these guidelines has its own strengths, as mentioned earlier, the CSCO guidelines, written by our experts, are the most relevant to our situation. Our population is large, geographically diverse, culturally diverse, and economically and socially uneven, and cancer care varies widely, so a single standard cannot meet the needs. The CSCO guidelines are a way to standardize the treatment of lung cancer patients in China and fit the actual national situation.

The 2018 CSCO lung cancer guidelines were updated at more points than in previous years, with updates based primarily on evidence-based medicine, including studies led or participated in by Chinese experts, such as the Brain study (exatinib) and the ADJUVANT study led by Professor Yilong Wu, and the AURA3 study (oseltinib) and the ARCHER1050 study (daclatinib) in which domestic scholars participated. (Dacitinib), etc. Secondly, the changes in the accessibility of treatment measures after the adjustment of national health insurance policy are also reflected in the recommendations of the guidelines. Finally, the results of some domestic drug studies were outstanding and were also included in the new guidelines. For new drugs that are involved in clinical studies domestically and have been approved internationally, they are presented as Level 3 evidence.

Such a guideline tailored for lung cancer patients in China is worth using.

Is there a lung cancer guideline specifically for patients and families?

The guidelines mentioned above are written for medical professionals, and are certainly obscure and difficult for patients and families to read, and are not recommended for non-medical people. However, in the life-and-death “battle” of cancer, it is important to know your enemy to win. So, is there a patient-specific “guide” that can help them understand the disease, understand the difficult terminology, and understand the basis for doctors’ decisions?

The answer is “yes.

The answer is “yes”.

The answer is “yes.

On the NCCN website, in addition to the NCCN Clinical Practice Guidelines for physicians, there are also the NCCN Guidelines for Patients. For example, there are two NCCN guidelines for patients: the lung cancer guidelines and the lung cancer screening guidelines, which can be downloaded for free (https://www.nccn.org/patients/guidelines/cancers.aspx). This guide is very detailed and basically covers a variety of issues in lung cancer treatment.

In addition, globally recognized academic oncology organizations such as the American Society of Clinical Oncology (ASCO) and the European Society of Medical Oncology (EMSO) have their own patient websites that provide patient guidelines or educational materials that can be downloaded and printed, only unfortunately these materials are in English.

ASCO’s patient guide website:

https://www.asco.org/practice-guidelines/resources-patients

ESMO’s patient guide website:

http://www.esmo.org/Patients/Patient-Guides

CSCO and China Medical Tribune have also jointly published a series of patient education manuals, including one for patients with lung cancer.

How do I properly understand and use the guideline information?

Read clinical guidelines and patient education materials to help better understand the disease, ask questions, communicate more smoothly with your doctor, and gain insight into your doctor’s treatment decisions.

But it is important to note that guidelines are recommendations based on clinical research evidence and expert experience, but it is not always true that this is appropriate for each patient’s individual situation. Some of the advice in foreign guidelines may not be suitable for our patients. More often than not, physicians do not follow guidelines mechanically, but rather make “individualized” recommendations based on the guidelines, taking into account the unique circumstances of each patient.

So if your doctor’s recommendations don’t exactly match the guidelines, you can talk to your doctor and find out what he or she thinks.