Tarot card
reader Estella Fortunado, 42, explains: "It's a matter
of gut feeling rather than of knowing what the cards
represent. I have a hunch everything's going to be okay."
It's a positive attitude for someone recently diagnosed
with breast cancer. Luckily the tumour was discovered
early on, but if, like her, Estella's doctor, believes
in following instincts rather than sticking to guidelines,
Estella's prognosis may not be so bright. According
to Canadian research published in the August issue of
the Journal of Clinical Oncology, patients whose
doctors chose to abide by their intuition ran a higher
risk of death and of tumour recurrence, than those treated
according to consensus recommendations.
The study
reviewed the medical records of 1,541 women diagnosed
with invasive node-negative breast cancer in Quebec
in the years 1988-1989, 1991-1992, and 1993-1994. The
treatment received by patients was compared to that
recommended by guidelines developed at the 1992 St-Gallen
conference in Switzerland, which describes when patients
should receive either tamoxifen, chemotherapy, neither,
or both, following surgery.
Sharp differences
were observed between those patients treated strictly
according to the St-Gallen guidelines and those whose
treatment departed from this plan. Patients were divided
into three groups based on the likelihood of recurrence.
Those at minimal risk were almost all treated according
to guidelines, so no meaningful comparison was possible.
But among those at moderate risk of recurrence, patients
whose treatment didn't follow guidelines were 2.3 times
more likely to die over the following seven years. Among
women at high risk, those whose treatment failed to
follow guidelines bore an additional 35% risk of death
over seven years.
Lead author
Dr Nicole Hébert-Croteau of the Quebec National
Institute of Public Health, said: "Women treated for
node-negative breast cancer according to consensus recommendations
for systemic therapy experience a significant improvement
in survival at seven years. Our associations support
the current movement for developing, updating and disseminating
such recommendations."
The most
common reason for departing from guidelines, Dr Hébert-Croteau
notes, is a desire to spare the patient the side effects
of cancer therapy. Naturally, she says, some patients
have co-morbid conditions that make following guidelines
impossible. But she believes physicians should know
that gentler treatment can come at a high price.
Other physicians
remark that while guidelines are a start, they're not
enough to ensure optimal patient care. In an accompanying
editorial, Dr Rebecca Silliman of Boston University
Medical Center argues that, "Although evidence-based
guidelines are a necessary beginning, they are not sufficient
in and of themselves to change practice. What is required
is a much more comprehensive approach that incorporates
not only knowledge, but also builds skills and affects
attitudes." Nonetheless, a simple list of recommendations
may save the lives of some women stricken by breast
cancer while veering off the guideline path can carry
a big risk.
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