ESMO 2010

Professor Andrés Cervantes – University of Valencia, Spain

Implementation of ESMO guidelines

You have been given a big responsibility here because we all know that guidelines are really important but you are chairing a meeting to talk about guidelines and actually how to actually apply them if you’re a busy clinician. What are the big challenges facing busy doctors?

The problem is how to, as an educational society as ESMO is, try to improve clinical practice. So Europe is growing in a very important way, we have many countries and we have a large heterogeneity in practice so we try to produce every year, and in fact this year we have published 55, guidelines covering all tumours and all special circumstances like cancer and pregnancy, cardiotoxicity of anti-tumour agents. So then for the last ten years we have been using our congress, every year, to have a guideline session. During this guideline session we are covering three topics and every year we ask one of the people elaborating that particular guideline and this year it’s going to be on triple negative breast cancer, GIST tumours and pancreatic cancer.

So people elaborating on those guidelines are going to discuss, in front of the audience, three clinical cases, three challenging clinical cases, and they are going to try to apply the guidelines, evidence-based guidelines to every case.

It is difficult for clinicians to keep up with the guidelines and to know how to prioritise. What recommendations would you make to doctors?

ESMO guidelines are not extensive papers, difficult to read; they are short papers, 3 – 5 pages each, in which all the main topics are underscored and people can go directly to check staging, treatment, multidisciplinary treatment, prognosis. So then, as a society, what we would really like to do is to offer our members, practical oncologists, a tool to go through the advances in cancer. Our guidelines are also evidence-based, they are produced by expert people and they are peer reviewed by four more experts.

Now you’re looking at triple negative breast cancer, pancreatic and also GIST. What are the golden rules that doctors need to bear in mind in trying to make sure they apply the guidelines?

Well a critical point is that if you are analysing the results you are getting in your patients, then if you are in alignment with the general trends I think you can say that you are in the right situation. But sometimes there is a gap between knowledge and practice so then guidelines are trying to make this gap shorter by giving a practical tool, short and handy, that they can apply then. So we have those guidelines published in Annals of Oncology but they are also on the ESMO web and they are accessible to all ESMO members so they can go very quickly to any tumour to get the most recent guidelines. And they are renewed every year.

Is there still a gap in 2010 between evidence based practice and authority based practice do you think?

Well that’s challenging but the main issue is that normally practising oncologists are not like in academic centres, experts in breast, colorectal or pancreatic cancer. So they are people working in small hospitals where they have to take care of a few patients of every disease. So then we have to be sure that the very basics of all requirements are accomplished by them.

Can you give me some idea of just how big a difference in outcomes you can get by adhering to the guidelines as compared with not adhering so well.

That’s difficult to say because I don’t know any studies or any practical studies exploring that point. But in general I would say that what has been shown in scientific trials, in randomised trials, if this has to be applied to the general practice then we have to set up very well what are the rules to be followed. And this is the main aim for guidelines.

Another area that you’re dealing with here in Milan at the ESMO meeting is rectal cancer, advanced rectal cancer. This, I know, is near to your heart, what new things are you going to tell us about this?

Well the aim of the decision we’ve got in this rectal cancer business is called the multidisciplinary interactive session. So these are sessions to be attended by a maximum of sixty people. I am going to discuss with very much an expert surgeon what are the interactions needed to improve practice. So then we will discuss two clinical cases and then we will be open to receive questions from the floor. The key point is that if you like to have a better outcome we should use the best of any part of the co-operation for the treatment of the patient. So good diagnosis, and I will stress the importance of MRI in getting rectal cancer patients very well staged before getting any decisions. Then we will go to a multi-disciplinary team discussion, how to discuss, what are the key points and which are the patients that should go to multi-disciplinary treatment or just to surgery or for chemoradiation before surgery. How, then, the quality of the surgical specimen has to be with all requirements, apart from the classical TNM system. We need other requirements, for example, the quality of the surgical specimen regarding planes of surgery. If our pathologists report very well on that it is giving us cues of how to treat the patient, how to assess the risk for the patient.

And the other new point that I think is very important, very solid, is the distance of the tumour from the circumferential margin. This information, when we are able to integrate this information into the classical TNM system, we will get better tools for selecting treatment for assessing prognosis and for getting better outcomes for our patients.

So quality is a big issue?

Quality is a big issue in rectal cancer because we need the participation of diagnosis then first MRI, this should be the first step for quality, treatment, surgical quality, pathology quality, everything. The best outcomes will come from the best global quality we can offer our patients.

Finally, what brief message would you give to doctors coming out of your guidelines and very much hands-on sessions that you’re running.

Well, as a member of the educational and guidelines committee, I would say ESMO is working hard offering doctors nice tools to keep up to date with new developments. Those new developments are going to be incorporated into the guidelines. We are going to improve our guidelines next year by doing some of them, the big killers, through a consensus conference process and I think this will improve the quality and the application of our guidelines.

Andrés, thank you very much for coming to see us and it’s been great having you here on ecancer.tv in Milan, and I wish you a happy journey back to that beautiful city of Valencia.