Guideline development process

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Guideline development process

Introduction

Cancer Council Australia (CCA) was commissioned by Cancer Australia (CA) to develop clinical practice guidelines for the treatment and management of endometrial cancer.

The guidelines were developed by a multidisciplinary working group (see Endometrial Cancer Guidelines Working party members). Topic leaders from the Working Party membership were designated to address topics in their areas of expertise, with other Working Group members contributing as co-authors.

The guideline development process, conducting the literature searches, appraising the literature and formulating and grading recommendations, followed the NHMRC guideline development process. These guidelines have been developed based on current available evidence. They will be reviewed in the next six months and then as appropriate as new evidence emerges

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Steps in preparing clinical practice guidelines

A clear strategy was developed and each topic author followed the appropriate steps in preparing their guideline sections. The Working Party developed clinical questions and topic groups were assigned to review and synthesise the relevant literature and to formulate evidence-based recommendations. The search strategy and literature search was conducted by the Project Officer, who distributed the search results to the Working Party authors.

The strategic steps followed are outlined below:

  1. Structure the research questions
  2. Develop a search strategy
  3. Search the literature
  4. Critically appraise the literature
  5. Formulate and grade recommendations

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Structure the research questions

The Working Party discussed the most important aspects of treatment for women with apparent early stage endometrial cancer and developed clinically focussed key questions. These questions were approved at the Working Party meeting on 27 September 2010.

The clinical questions asked for the low and high risk apparent early stage disease, are as follows:


Multidisciplinary care

1. Is there benefit for multidisciplinary care of women with low and high-risk apparent early stage endometrial cancer?

Pre-operative

2. What is the role of preoperative imaging for low and high risk apparent early stage endometrial cancer?

3. Is there a benefit to a histopathological review of currettings or biopsy prior to treatment in low and high risk apparent early stage endometrial cancer?

Surgery

4. What is the evidence based surgical approach for hysterectomy in low and high risk apparent early stage endometrial cancer?

5. What is the evidence based surgical approach for bilateral salpingo–oophorectomy in premenopausal women with low and high risk apparent early stage endometrial cancer?

6. What is the evidence based surgical approach for lymphadenectomy in low and high risk apparent early stage endometrial cancer?

7. What is the role of intra-operative assessment of the uterus in low and high risk apparent early stage endometrial cancer?

Adjuvant Therapy

8. After hysterectomy, what is the role of radiotherapy (external beam, brachytherapy) in the management of early stage high risk endometrial cancer?

9. After hysterectomy, what is the role of chemotherapy (concurrent/concomitant, sequential, sandwich, chemoradiation) in the management of early stage high risk endometrial cancer?


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Develop a search strategy

Appropriate search strategies were constructed for each clinical question. MeSH terms were agreed by the Working Party members and where expanded by the Project Officer after conducting pilot searches and searching the MeSH vocabulary. MeSH index terms were translated to Emtree terms for the Embase database to ensure that appropriate index terms unique to each database were used. When there was no appropriate MeSH or Emtree index term available a combination of free text words were used in order to capture the relevant data.

The following exclusion criteria was applied: studies published pre 1995, languages other than English, surgical stage III or IV, advanced, recurrent, metastatic or disseminated endometrial cancer and the following study designs: nonsystematic reviews, case series, case reports, animal, in vitro and laboratory studies and communication such as letters to the editor and journal commentary. The search strategy was approved by the Chair of the Working Party.

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Search the literature

A range of medical databases, guideline clearinghouses and clinical trial portals were searched. These included The Cochrane Library, PubMed, Embase, PsycINFO, CINAHL, Scopus, Informit, Trip Database, the National Guideline Clearinghouse, WHO International Clinical Trials Search Portal, the metaRegister of Controlled Trials, the National Institute of Health Registry and the IFPMA Clinical Trials Portal. Search results were screened for relevance by the Project Officer and relevant literature was collated, the full text articles obtained and sent to Working Party topic authors to critically appraise, synthesise and use as the evidence base for their topic questions.

To view the complete search yield and more detailed information about the literature search such as inclusion and exclusion criteria, please go to each clinical question page. The documentation can be found under the heading 'Supporting material'.

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Critically appraise the literature

Relevant articles selected from the literature search were reviewed by the clinical question authors and each article was critically appraised with respect to level of evidence, quality of the evidence, size of the effect and clinical importance and relevance. Level of evidence was assigned according to the following criteria adapted from the NHMRC Evidence Hierarchy:

Level Intervention Diagnosis Prognosis Aetiology Screening
I A systematic review of level II studies A systematic review of level II studies A systematic review of level II studies A systematic review of level II studies A systematic review of level II studies
II A randomised controlled trial A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among consecutive patients with a defined clinical presentation A prospective cohort study A prospective cohort study A randomised controlled trial
III-1 A pseudo-randomised controlled trial (i.e. alternate allocation or some other method) A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among non-consecutive patients with a defined clinical presentation All or none All or none A pseudo-randomised controlled trial (i.e. alternate allocation or some other method)
III-2 A comparative study with concurrent controls:
  • Non-randomised, experimental trial
  • Cohort study
  • Case-control study
  • Interrupted time series with a control group


A comparison with reference standard that does not meet the criteria required for Level II and III-1 evidence Analysis of prognostic factors amongst untreated control patients in a randomised controlled trial A retrospective cohort study A comparative study with concurrent controls:
  • Non-randomised, experimental trial
  • Cohort study
  • Case-control study


III-3 A comparative study without concurrent controls:
  • Historical control study
  • Two or more single arm study
  • Interrupted time series without a parallel control group


Diagnostic case-control study A retrospective cohort study A case-control study A comparative study without concurrent controls:
  • Historical control study
  • Two or more single arm study


IV Case series with either post-test or pre-test/post-test outcomes Study of diagnostic yield (no reference standard) Case series, or cohort study of patients at different stages of disease A cross-sectional study Case series

Source: National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC; 2009.[1] (https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf)

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Formulate and grade recommendations

The body of literature was assessed by each topic author and recommendation grades were assigned using the following criteria adapted from the NHMRC body of evidence matrix:

Component of Recommendation
Recommendation Grade
A
Excellent
B
Good
C
Satisfactory
D
Poor
Volume of evidence several level I or II studies with low risk of bias one or two level II studies with low risk of bias or SR/multiple level III studies with low risk of bias level III studies with low risk of bias, or level I or II studies with moderate risk of bias level IV studies, or level I to III studies with high risk of bias
Consistency all studies consistent most studies consistent and inconsistency may be explained some inconsistency reflecting genuine uncertainty around clinical question evidence is inconsistent
Clinical impact very large Substantial moderate slight or restricted
Generalisability population/s studied in body of evidence are the same as the target population for the guideline population/s studied in the body of evidence are similar to the target population for the guideline population/s studied in body of evidence different to target population but it is clinically sensible to for guideline to apply this evidence to target population population/s studied in body of evidence different to target population and hard to judge whether it is sensible to generalise to target population
Applicability directly applicable to Australian healthcare context applicable to Australian healthcare context with few caveats probably applicable to Australian healthcare context with some caveats not applicable to Australian healthcare context

Source: National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC; 2009.[1] (https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf)

Recommendation grades are indicated below:

Grade of recommendation
Description
A
Body of evidence can be trusted to guide practice
B
Body of evidence can be trusted to guide practice in most situations
C
Body of evidence provides some support for recommendation(s) but care should be taken in its application
D
Body of evidence is weak and recommendation must be applied with caution
PP
(practice point)
Where no good-quality evidence is available but there is consensus among Guideline committee members, consensus-based guidance points are given, these are called "Practice points"

Adapted from: National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC; 2009.[1] (https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf)

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Write the topic content

Topic authors were asked to write the content for their guideline topic questions using the following format:

  • background
  • review of the evidence
  • evidence summary with levels of evidence and numbered references
  • recommendation(s) and corresponding grade(s)
  • references

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Review of the topic content

The body of evidence and recommendations for each topic question were reviewed by the Guidelines Working Party and final recommendations agreed to, based on the evidence.

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Public consultation

A complete draft of the guidelines was sent out for public consultation to all interested parties in Australia for the period from 4 July to 4 August 2011. The consultation process involved soliciting public review of the draft guidelines through posting onto the Cancer Council Australia online Wiki platform and alerting professional societies and groups and sponsors via link to the site.

All feedback on the draft received during the consultation period in Australia was reviewed by the Guidelines Working Party topic authors. Subsequent changes to the draft were agreed by consensus, based on consideration of the evidence.

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References

  1. 1.0 1.1 1.2 National Health and Medical Research Council. NHMRC Australian Guidelines to reduce health risks from drinking alcohol. Commonwealth of Australia: National Health and Medical Research Council; 2009 Jan 1 [Abstract available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ds10-alcohol.pdf].