The first Australian evidence-based “Clinical guidelines for the prevention, diagnosis and management of lung cancer” were published in a paperback format in 2004 with endorsement by the National Health and Medical Research Council. Since then, the lung cancer evidence base has grown almost exponentially, particularly in the area of treatment. By 2010, a revision was long overdue and it was recognised that the printed format was unsuited to keeping pace with the regular stream of new knowledge. The solution proposed by Cancer Council Australia (CCA) was a web accessible electronic version of the guidelines in a “wiki” format that would allow editing and updating by expert standing committees as soon as new evidence became available.
In a project commissioned by Cancer Australia (CA), CCA undertook to develop a sustainable web-based wiki platform with revised guidelines for the treatment of lung cancer as the first topic.
The scope of the revision was limited in this first phase to the treatment of non-small cell and small cell lung cancer (chapters 5 and 6 respectively of the 2004 version) and supporting the patient and palliative care (chapters 4, 7 and 8). A working party of 22 clinicians (see Appendix), representing the range of specialties engaged in treating lung cancer including respiratory medicine, thoracic surgery, radiation oncology, medical oncology and palliative care, were brought together and assigned topics in their area of expertise. Most Australian states were represented on the working party, and New Zealand was represented in the process by Dr Jeff Garrett. Unlike the 2004 guidelines, in which the content was set out according to treatment modality, we decided to organise the questions according to disease stage. This was an acknowledgment that it is stage rather than modality that is relevant for clinical decision making, and that in each stage, optimal treatment is often multimodality. The questions on palliative care were prepared separately, as it is accepted that referral to palliative care can be appropriate at any stage of the disease.
The importance of the multidisciplinary team in initial assessment, diagnosis and making recommendations about treatment is strongly endorsed for all patients with lung cancer, but the evidence surrounding their role in overall lung cancer management was not within the scope of the current project, and will be addressed in the next phase of the revision.
The working party were asked to prepare questions relevant to their sections, resulting in 67 clinical questions. The project officers conducted a literature search based on those questions, retrieving 22,211 results. After excluding studies with methodologic problems, and further searching, 2,324 articles were identified and forwarded to the authors for appraisal using an online scoring tool derived from the NHMRC principles for assessing clinical evidence. Finally, 1,222 articles were deemed worthy of appraisal using the PICO (population, intervention, comparator, outcome) methodology. The authors then wrote brief descriptions of the evidence and summarised it with a grade of recommendation (levels A-C). Where the quality of the evidence was below grade C, or it is unlikely there will ever be high level evidence, for example for an uncommon clinical scenario, the authors added practice points. In January 2012, the working party was instructed to review the content using an online commenting tool. One hundred and fifty six (156) working party member comments were received in nine weeks, which fine-tuned the content. The project officer then double checked the grade of recommendation against the source documents.
The draft guidelines containing 113 recommendations and 72 practice points were released online for public consultation for a 30 day period on 1 May 2012. The consultation process involved soliciting public comments by sending email alerts to 256 email recipients comprising relevant professional organisations, state and territory Cancer Councils and individual clinical experts and consumer organisations in Australia and New Zealand, and inviting them to post their comments on the Cancer Council Australia Cancer Guidelines Wiki. During the consultation process, there were 995 visitors to the website. Nineteen (19) submissions were received with 38 comments. These led to further edits to the draft guidelines after the working party considered all the public comments.
The guidelines resulting from this exhaustive and rigorous process are now available online, but they are not final, and never will be. The guidelines represent a living document an interactive forum for comment and debate and an opportunity to bring new evidence to the lung cancer community within a short time frame. We invite readers who become aware of new evidence to create a personal account on the wiki and make comment online in the appropriate section, so that the working party can consider whether it should change any of the recommendations.
Users need to be warned that most of the evidence evaluated necessarily predates the 2010 implementation of the 7th edition of the TNM staging system, and where there are differences between the 6th and 7th editions, this needs to be taken into account when applying the recommendations. There have also been recent changes in the pathology subclassification of adenocarcinoma, and in the molecular characterisation of non-small cell lung cancer, for which the evidence for optimal treatment is still emerging.
Further work on the guidelines will continue, with the topics of prevention, screening, diagnosis and assessment to be considered next.
I believe the wiki guidelines format resulting from this project is internationally unique, and provides a model for others to follow. We hope the wiki will be an accessible up-to-date resource for multi-disciplinary teams, individual clinicians, students and consumers. I congratulate CCA on the wiki’s attractive, easy-to-navigate and interactive website, and the features that enable visitors to link to the source literature underpinning the recommendations.
I would like to thank my many colleagues on the working party who gave voluntarily of their time to appraise the evidence, write the recommendations and meet the deadlines. I also thank Cancer Australia’s Lung Cancer team and the CEO of Cancer Council Australia, Professor Ian Olver for their support and guidance. And finally I wish to acknowledge the enormous amount of work done by the project team at CCA: Laura Holliday and Alice Winter-Irving, the project officers who sifted the evidence; and Christine Vuletich and Jutta von Dincklage who kept the project moving and provided the professional finish to the product that follows.
Professor David Ball MB BS, MD, FRANCZR
Chair, Lung Cancer Guidelines Working Party
Peter MacCallum Cancer Centre, Victoria
- National Health and Medical Research Council. How to use the evidence: assessment and application of scientific evidence. Commonwealth of Australia: National Health and Medical Research Council; 2000 Jan 1 [Abstract available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp69.pdf].
- National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for guideline developers. Canberra: National Health and Medical Research Council; 2009 Available from: https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf.