DMP for breast cancer: Current guidelines show need for change

On 25 November 2008, the German Institute for Quality and Efficiency in Health Care (IQWiG) presented the results of a search for new or updated evidence-based clinical practice guidelines (CPGs) on breast cancer. The aim of the report was to identify key recommendations from current CPGs of high methodological quality that could be relevant to the planned revision of the disease management programme (DMP) for breast cancer. According to the results, the statements in the DMP do not contradict the current CPGs. However, there seems to be a need for amendment of the DMP, as some innovations, in particular regarding antibody therapy, have not yet been considered.

Evidence documented in detail

On behalf of the German Federal Joint Committee, IQWiG systematically searched for new or updated CPGs, assessed their methodological quality, and compiled relevant recommendations from the CPGs. These recommendations refer to the areas diagnosis, therapy, after-care, and rehabilitation, as well psychosocial care and patient information. In addition, IQWiG documented the scientific evidence provided in the CPGs for these recommendations. However, the evidence provided was not reviewed; this is where IQWiG's CPG appraisals differ from its benefit assessments.

No contradictions between the DMP and current recommendations

A total of 23 evidence-based CPGs were included that contained recommendations on the treatment of breast cancer. As the assessment showed, the recommendations in the CPGs were largely consistent with those in the DMP. However, IQWiG found information on some innovations in the CPGs that require a discussion on the modification of the DMP. In particular this refers to antibody therapy with trastuzumab as a general indication for the treatment of certain types of breast cancer. This drug was approved in Germany for adjuvant therapy of breast cancer after the last DMP revision.

In addition, the current CPGs address several health care aspects in a more detailed manner than the DMP, such as diagnostics, surgical therapy, radiation therapy, systemic therapy, psychosocial care, and after-care. For example, IQWiG sees a potential need for amendment and specification of the DMP concerning the whole area of systemic therapy. In contrast to the DMP, with regard to endocrine therapy and chemotherapy, the CPGs name individual drugs and treatment regimens.

Some guidelines also recommend using the services of "breast care nurses”, i.e., specifically trained nursing experts for breast diseases.

Procedure of report production

The preliminary results (preliminary report) were published by IQWiG at the end of April 2008, and interested parties were invited to submit comments. As the written comments received did not contain unclear aspects and no questions remained open, the Institute dispensed with an oral debate. After the hearing procedure, the preliminary report was revised and the final report was sent to the contracting agency (the Federal Joint Committee) at the end of September 2008. A documentation of the written comments was published in a separate document simultaneously with the final report.

The executive summary provides an overview of the background, methods, and further results of the final report.