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CMAJ and CTFPHC Require Accountability and Adherence to Guidelines for Guidelines

  • Shushiela Appavoo, Radiologist, University of Alberta
  • Other Contributors:
    • Laurence Klotz, Professor of Surgery, Sunnybrook Health Sciences Centre
    • Eric M. Yoshida, Professor of Medicine, University of British Columbia
    • Paula B Gordon, Clinical Professor of Radiology, University of British Columbia
    • Jean Seely, Professor of Radiology, The Ottawa Hospital
    • Martin Yaffe, Professor, Depts. Medical Biophysics and Medical Imaging, Sunnybrook Research Institute, University of Toronto
9 May 2019

The CMAJ’s recent editorial on competing interests in guidelines is appropriate, but there is also a need to reform the current CTFPHC guidelines process (1).

The CTFPHC explicitly and systematically excludes substantive expert advice. This extraordinary policy has handicapped the guidelines and rendered many of them clinically outdated, misleading, and even dangerous. Most internationally recognized “Guidelines on Guidelines” emphasize the importance of adequate clinical expert and patient stakeholder advice (2-4). Including expert opinion, as per the current “Guidelines on Guidelines” (2-4), is a much-needed antidote to the CTFPHC policy.

We recognize and acknowledge the problems inherent in financial and intellectual conflicts of interest when introducing expert input. These can be disclosed and mitigated. Without content experts, these guidelines are simply uninformed literature reviews and meta-analyses, without meaningful insight or guidance in the specifics of disease biology, advances in treatment and medical technology, as well as lacking the nuances involved in interpreting inferential data which may not derive from prospective randomized trials. Many of the CTFPHC Guidelines have been strongly criticized by national specialty societies and renowned experts. (letters/position statements appended), seriously undermining the credibility of the guidelines as well as their clinical application.

Inherent in the CTFPHC approach is the ideology that specialists are so conflicted by greed, self-interest, and a lack of insight that their knowledge and experience are biased, worthless and unwelcome. This is demeaning, unproductive, divisive and, most importantly, is detrimental to patients and society.

The CMAJ published and cited a commentary by a US physician, Dr Ismail Jatoi, who generalizes an American perspective on the business of health care to a dramatically different Canadian environment. Many Canadian specialists have long wait lists and Canadian specialists in a public system are not trying to use screening policies to increase their business. In Canada, screening studies tend to be the lowest paid and most QA-intensive activities in their practices, so increasing screening is counterintuitive to a successful business model (5).

Dr. Jatoi seems to seek conflict of interest where there is none. Citing his own opinions, he attributes the differences between the CTFPHC and the Canadian Association of Radiologists’ Breast Imaging and Intervention Guidelines recommendations to bias, rather than specialty knowledge. Dr. Jatoi appears to ignore the wealth of peer-reviewed data on which the specialist guidelines are formulated.

If CMAJ used a Guideline for Guidelines, and the CTFPHC appropriately applied GRADE rules in a transparent and accountable fashion the result would be more useful and appropriate guidelines, greater harmony between specialist guidelines and CTFPHC guidelines as well as less confusion for health care providers, patients and the public.

Conflicts of interests go in both directions. The CTFPHC is a government funded body, and one could just as easily speculate that there is a bias towards government cost savings above clinical benefit. The chair of the breast screening guidelines is an expert on health economics.

Patients and health care providers trust the national guidelines body to form safe and useful patient-centered guidelines with expert input and consensus. What confidence would they have if it was known that the best experts in their medical fields have been explicitly excluded because of broad based and unsubstantiated accusations of self-interest and bias? The CTFPHC must adopt more appropriate guideline development practices which incorporate the benefit of the depth of knowledge and experience of Canadian specialists.

We encourage readers to review the expert opinion on the science behind the CTFPHC guidelines in the published responses and position statements from experts and leaders of national and provincial specialty bodies.

Respectfully,

Pauline Alakija, MSc, MD, FRCPC
Anatomical and Forensic Pathologist, DynaLife Medical Labs
Clinical Professor, Department of Laboratory Medicine and Pathology, Faculty of Medicine, University of Alberta
Past President, Misericordia Medical Staff Association
Chair, Governance Committee, College of Physicians and Surgeons of Alberta

Kimberly Anderson-Hill, MD, CCFP
Clinical Lecturer, University of Alberta, Department of Family Medicine
Lead physician, Synergy Women’s Wellness Centre

Shushiela Appavoo, MD, FRCPC
Assistant Clinical Professor, University of Alberta
Chair, Canadian Association of Radiologists Breast Imaging Guidelines Working Group
VP, Canadian Society of Breast Imaging

Yvonne M Buys, MD, FRCSC
Professor, Department of Ophthalmology and Vision Sciences, University of Toronto
President, Canadian Ophthalmological Society

Chris de Gara, MB, MS, FRCS(Ed, Eng and C), FACS FFSted
Professor Emeritus (retired), University of Alberta
Past President, Canadian Association of General Surgeons
Former Director of Bariatric Surgery Revision Clinic, Alberta Health Services
Now Medical Panels Commissioner Ministry of Labour Government of Alberta

Beth Donaldson, MD, CCFP
Medical Director Copeman Healthcare

Allison S Geffen, BA, MD, CCFP, FCFP
Lecturer, University of Ottawa

S. Larry Goldenberg, CM, OBC, MD, FRCSC, FCAHS, FACS
Jarislowski Professor of Urologic Sciences,
University of British Columbia and Vancouver General Hospital
Director of Development and Supportive Care, Vancouver Prostate Centre
Chair, Canadian Men’s Health Foundation

Paula B Gordon, OBC, MD, FRCPC, FSBI
Clinical Professor of Radiology
University of British Columbia

Alan Iny, CCFP
Assistant Professor, University of Ottawa
Faculty of Department of Family Medicine

Laurence Klotz, MD, FRCSC, CM
Professor of Surgery, University of Toronto
Sunnybrook Chair of Prostate Cancer Research
Chairman, World Urologic Oncology Federation
Chairman, SIU UCare Research Office
Chairman, Canadian Urology Research Consortium
Sunnybrook Health Sciences Centre

Rhonda Low, MD, CCFP, FCFP
Clinical Associate Prof: Dept. Family & Community Medicine
University of British Columbia

Natalie Mills, MDCM, CCFP
Assistant Professor, University of Ottawa, Family Medicine Department
East Region Investigating Coroner for the Province of Ontario
Patient Advocate for The Ottawa Hospital, Cancer Care Ontario and The Canadian Partnership Against Cancer
Patient Advocate for The Canadian Society of Breast Imaging

Angela Nguan, MD, CCFP
Copeman Healthcare Centre

Jean Seely, MD, FRCPC, FSBI
Professor of Radiology
University of Ottawa
Head of Breast Imaging
The Ottawa Hospital
President, Canadian Society of Breast Imaging

Wei-Yi Song, MD, FRCPC
Clinical Professor, University of British Columbia
President, Canadian Psychiatric Association

Michele D. Thomasse, MD, CCFP
Clinical Teaching Associate, University of British Columbia

Anna N. Wilkinson, MSc., MD, CCFP, FCFP
Assistant Professor, University of Ottawa, Department of Family Medicine
Family Physician, The Ottawa Academic Family Health Team
GP Oncologist, The Ottawa Hospital Cancer Centre
Program Director, PGY-3 FP-Oncology

Martin J. Yaffe, PhD, C.M., Hon.D.Sc.
Senior Scientist, Physical Sciences
Tory Family Chair in Cancer Research
Sunnybrook Research Institute
Professor, Depts. Medical Biophysics and Medical Imaging
University of Toronto
Co-Director, Imaging Research Program
Ontario Institute for Cancer Research

Eric M. Yoshida, OBC, MD, MHSc, FRCP(C), FACP, FACG, FCAHS, FAASLD
Professor of Medicine
University of British Columbia
&
Division of Gastroenterology
Vancouver General Hospital

REFERENCES
1. Kelsall D. New CMAJ policy on competing interests in guidelines. Canadian Medical Association Journal. 2019;191(13):E350-E1.
2. Schiffman RN. Recognizing Trustworthy Guidelines: The New IOM Standards New Haven, CT: Yale School of Medicine; 2019 [cited 2019 April 29]. Available from: https://www.cdc.gov/od/science/quality/docs/trustworthy_gls.pdf.
3. Qaseem A, Forland F, Macbeth F, Ollenschläger G, Phillips S, van der Wees P, et al. Guidelines International Network: Toward International Standards for Clinical Practice Guidelines. Annals of Internal Medicine. 2012;156(7):525-31.
4. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839-42.
5. Jatoi I, Sah S. Clinical practice guidelines and the overuse of health care services: need for reform. Canadian Medical Association Journal. 2019;191(11):E297-E8.

RESPONSE LETTERS AND POSITION STATEMENTS

Cervix screening: Cervical Screening Guidelines -discordance discussed
http://www.cmaj.ca/content/185/1/35/tab-e-letters#cervical-screening-gui...

Colorectal screening: Colonoscopy is probably the best colon cancer screening test, it's not proven yet
http://www.cmaj.ca/content/188/5/340/tab-e-letters#colonoscopy-is-probab...

Developmental delay screening: Take home message of Task Force report: NOT the strong recommendation against developmental screening, BUT the need for rigorous research and practice
http://www.cmaj.ca/content/188/8/579/tab-e-letters#take-home-message-of-...

Hepatitis C screening: Recommendations on hepatitis C screening for Adults CMAJ 2017 April 24;189:E594-604. doi: 10.1503/cmaj.161521
http://www.cmaj.ca/content/189/16/E594/tab-e-letters#recommendations-on-...

Impaired Vision screening: RE: Screening for impaired vision in community-dwelling adults aged 65 years and older in primary care settings
http://www.cmaj.ca/content/190/19/E588/tab-e-letters#re-screening-for-im...

Lung Cancer screening: The Consequences of A Short Duration of Lung Cancer Screening
http://www.cmaj.ca/content/188/6/425/tab-e-letters#the-consequences-of-a...

Adult Obesity recommendations: Canadian Task Force on Preventive Health Care* Recommendations for prevention of weight gain and use of behavioural and pharmacologic interventions to manage overweight and obesity in adults in primary care
http://www.cmaj.ca/content/187/3/184/tab-e-letters#canadian-task-force-o...

Canadian Society of Breast Imaging position statement on CTFPHC Breast screening recommendations: https://csbi.ca/wp-content/uploads/2019/05/CSBI_Statement_CTFPHC_Dec_201...

Canadian Association of Radiologists position statement on CTFPHC Breast screening recommendations: https://car.ca/wp-content/uploads/2019/02/CAR_Statement_CTFPHC_2019_02_0...

Canadian Urological Association position statement on CTFPHC Prostate screening guidelines: https://www.cua.org/themes/web/assets/files/psa/cua_response_to_ctfphc_p...

Competing Interests: • Dr. Gordon is a radiologist practicing breast imaging and image-guided biopsies. • Dr. Klotz reports personal fees from mirScientific, outside the submitted work. • Dr. Yaffe's lab conducts some collaborative research in the area of breast cancer imaging with GE Healthcare. Dr. Yaffe is a shareholder in Volpara Health Technologies. • Dr. Yoshida reports grants from Merck Canada, during the conduct of the study; grants from Gilead Sciences, grants from AbbVie, grants from Merck Inc, grants from Janssen, personal fees from Abbvie Canada, personal fees from Gilead Canada, grants from Intercept, grants from Genfit, personal fees from Merck Canada, personal fees from Celgene Canada, grants from Springbank, outside the submitted work.
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