TY - JOUR
T1 - Levels of Evidence for Radiation Therapy Recommendations in the National Comprehensive Cancer Network (NCCN) Clinical Guidelines
AU - Noy, Miguel Angel
AU - Rich, Benjamin J.
AU - Llorente, Ricardo
AU - Kwon, Deukwoo
AU - Abramowitz, Matthew
AU - Mahal, Brandon
AU - Mellon, Eric A.
AU - Zaorsky, Nicholas G.
AU - Dal Pra, Alan
N1 - Funding Information:
The reliance on new technologies within radiation oncology poses unique challenges in generating level I evidence based on randomized controlled data. 19 , 20 Once technology becomes available, the community tends to quickly adopt certain practices based on technological benefits before proof of patient benefit is derived from higher level studies. In addition, the field of radiation oncology is grossly underfunded in the United States relative to its role in cancer care. The proportion of National Institutes of Health funding that goes into radiation research is only 1.6% of the National Institutes of Health budget provided for cancer research. 21 Given these headwinds, it is perhaps not surprising that the Drugs and Biologics Compendium has a greater reliance on category I recommendations. Systemic therapy trials are heavily supported by industry funding, and previous work has addressed whether financial conflicts of interest have affected NCCN recommendations. 22 , 23
Publisher Copyright:
© 2021 The Author(s)
PY - 2022/1/1
Y1 - 2022/1/1
N2 - Purpose: The National Comprehensive Cancer Network (NCCN) clinical guidelines influence medical practice, payor coverage, and standards of care. The levels of evidence underlying radiation therapy recommendations in NCCN have not been systematically explored. Herein, we aim to systematically investigate the NCCN recommendations pertaining to the categories of consensus and evidence (CE) for radiation therapy. Methods and Materials: We evaluated the distribution of CE underlying current treatment recommendations for the 20 most prevalent cancers in the United States with at least 10 radiation therapy recommendations in the NCCN clinical guidelines. For context, the distribution of evidence in the radiation therapy guidelines was compared with that of systemic therapy using a χ2 test. The proportion of category I CE between radiation and systemic therapy was compared using a 2-proportion, 2-tailed z-test in total and for each disease site. A P value of <.05 was considered significant. Results: Among all radiation therapy recommendations, the proportions of category I, IIA, IIB, and III CE were 9.7%, 80.6%, 8.4%, and 1.3%, respectively. When analyzed by disease site, cervix and breast cancer had the highest portion of category I CE (33% and 31%, respectively). There was no radiation therapy category I CE for hepatobiliary, bone, pancreatic, melanoma, and uterine cancers. There was a significant difference in the distribution of CE between the systemic therapy recommendations and the radiation therapy recommendations (χ2 statistic 64.16, P <.001). Overall, there was a significantly higher proportion of category I CE in the systemic therapy recommendations compared with the radiation therapy recommendations (12.3% vs 9.7%, P =.043). Conclusions: Only 9.7% of radiation therapy recommendations in NCCN guidelines are category I CE. The highest levels of evidence for radiation therapy are in breast and cervical cancers. Despite major advances in the field, these data underline that the majority of NCCN radiation therapy recommendations are based on uniform expert opinion and not on higher level evidence.
AB - Purpose: The National Comprehensive Cancer Network (NCCN) clinical guidelines influence medical practice, payor coverage, and standards of care. The levels of evidence underlying radiation therapy recommendations in NCCN have not been systematically explored. Herein, we aim to systematically investigate the NCCN recommendations pertaining to the categories of consensus and evidence (CE) for radiation therapy. Methods and Materials: We evaluated the distribution of CE underlying current treatment recommendations for the 20 most prevalent cancers in the United States with at least 10 radiation therapy recommendations in the NCCN clinical guidelines. For context, the distribution of evidence in the radiation therapy guidelines was compared with that of systemic therapy using a χ2 test. The proportion of category I CE between radiation and systemic therapy was compared using a 2-proportion, 2-tailed z-test in total and for each disease site. A P value of <.05 was considered significant. Results: Among all radiation therapy recommendations, the proportions of category I, IIA, IIB, and III CE were 9.7%, 80.6%, 8.4%, and 1.3%, respectively. When analyzed by disease site, cervix and breast cancer had the highest portion of category I CE (33% and 31%, respectively). There was no radiation therapy category I CE for hepatobiliary, bone, pancreatic, melanoma, and uterine cancers. There was a significant difference in the distribution of CE between the systemic therapy recommendations and the radiation therapy recommendations (χ2 statistic 64.16, P <.001). Overall, there was a significantly higher proportion of category I CE in the systemic therapy recommendations compared with the radiation therapy recommendations (12.3% vs 9.7%, P =.043). Conclusions: Only 9.7% of radiation therapy recommendations in NCCN guidelines are category I CE. The highest levels of evidence for radiation therapy are in breast and cervical cancers. Despite major advances in the field, these data underline that the majority of NCCN radiation therapy recommendations are based on uniform expert opinion and not on higher level evidence.
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U2 - 10.1016/j.adro.2021.100832
DO - 10.1016/j.adro.2021.100832
M3 - Article
C2 - 34869943
AN - SCOPUS:85122531011
SN - 2452-1094
VL - 7
JO - Advances in Radiation Oncology
JF - Advances in Radiation Oncology
IS - 1
M1 - 100832
ER -