Curr Oncol, Vol. 22, pp. e61-68; doi: http://dx.doi.org/10.3747/co.22.

2235
VARIATION IN UPTAKE OF A GUIDELINE IN HEAD-AND-NECK CANCER
OR IGI NA L A RTICLE

Adherence to and uptake of clinical

practice guidelines: lessons learned
from a clinical practice guideline on
chemotherapy concomitant with
radiotherapy in head-and-neck cancer
S.F. Hall msc md,* J.C. Irish msc md,*
R.W. Gregg md, P.A. Groome phd,||
and S. Rohland||
ABSTRACT should be included during both development and
review of guidelines.
Background
KEY WORDS
Clinical practice guidelines (cpgs) are systematically
developed statements designed to assist practitioners Clinical practice guidelines, uptake, variation, head-
and patients in making decisions about appropriate and-neck cancer, chemoradiotherapy
heath care interventions. Clinical practice guidelines
are expensive and time-consuming to create. A cpg 1. INTRODUCTION
on concurrent chemotherapy with radiation therapy
(ccrt) was developed in Ontario at a time when Clinical practice guidelines (cpgs) are systematically
treatment approaches for head-and-neck cancer were developed statements designed to assist practitioners
changing significantly. and patients in making decisions about appropriate
heath care interventions for specific clinical circum-
Methods stances1. Evidence demonstrates that cpgs can influ-
ence the processes and outcomes of care24.
An assessment of treatments and outcomes based on To inform their recommendations, high-quality
electronic and chart data obtained from a population- cpgs use evidence that is typically selected, appraised,
based study of 571 patients with oropharynx cancer and synthesized using systematic review methods5. In
treated in Ontario (20032004) was combined with trying to craft recommendations for important clinical
a review of relevant knowledge transfer (publications questions, the cpg process can be challenged when the
and presentations at major meetings) to understand quality of the evidence is poor or its quantity is scant3.
variation in adherence to a cpg. Such was the case with a cpg produced by the Head
and Neck Cancer Disease Site Group of the Program in
Results Evidence-Based Care, the cancer guidelines program
of the provincial cancer agency Cancer Care Ontario
In 9 Ontario cancer treatment centres, ccrt was used for (cco). One cpg published in 2000 addressed the question
55% of all patients with oropharyngeal cancer; however, of the effectiveness of the addition of chemotherapy to
at the centres individually, that proportion ranged from radiotherapy for head-and-neck cancer6,7 based on a sys-
82% to 39%. Furthermore, there was no agreement on tematic review of the evidence between 1970 and 2000.
the chemotherapy regimen: 24 years later (a period The cpg recommended that concomitant chemo-
during which newer regimens were emerging), only 4 of therapy with conventional radiotherapy (ccrt) be the
9 centres were following the guideline for most patients. treatment of choice for patients with locally advanced
When outcomes of treated patients were compared for squamous cell carcinoma, noted that the ideal agent
centres with higher and lower use of ccrt, no dif- had yet to be identified, and proposed two regimens
ference in survival was observed (p= 0.64). as reasonable options outside the setting of a clinical
trial. However, from the outset, considerable concern
Conclusions was raised concerning the lack of quality data8,9 about
the incidence of major late toxicity1013, with a modest-
At a time of treatment evolution, the new guideline at-best survival advantage of 8%14 against a backdrop
was controversial, and there are many reasons for of years of unsuccessful trials investigating the use of
the mixed adherence. An estimation of adherence chemotherapeutic agents in patients with cancers of

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 HALL et al.
the head and neck. Despite those limitations, 60% of
practitioners responding during the external review
step of the guideline development process15 indicated
that the guideline should be approved, and 75% in-
dicated that they were likely or very likely to use it7.
The objective of the present study was to docu-
ment adherence to the cpg recommendations by the
cancer centres across Ontario that approved it and to
examine changes in the evidence that were occurring
at the time. The manuscript is divided into sections
about the clinical story and the educational events
near the time of the guideline. The first part uses a
population-based study of patients from 20032004
to examine patients, treatments, and outcomes. The
second part reviews the frequency and content of ccrt
presentations at major conferences and in publica-
tions between 1997 and 2003. With respect to the
clinical study, the years 2003 and 2004 were chosen
specifically because uptake was known to vary, thus
creating natural experiments that would allow for an
assessment of outcomes despite selection bias1618.
2. THE GUIDELINE
The cpg7 was published in 2000 based on survival
evidence from 20 randomized comparisons (1970
into 2000) of patients with locally advanced stage
iii or iv squamous cell head-and-neck cancer iden-
tified in literature searches (medline , cancerlit,
Healthstar, and Cochrane Library) and concluded
that survival improved with ccrt compared with
conventional radiotherapy alone. These were some
of the key recommendations:
Concomitant chemotherapy with conventional
fractionated radiotherapy should be the treatment
of choice for patients with advanced squamous
cell head-and-neck cancer,
At this time, the data are insufficient to recom-
mend the use of concomitant chemotherapy with
altered fractionation schedules.
The choice of concomitant therapy should take
into account the toxicity produced by various
regimens and the convenience of treatment admin-
istration. An examination of individual trial results
and toxicity profiles with the use of concomitant
cisplatin-based treatment suggests that, given the
circumstances, reasonable options outside a clini-
cal trial include either single-agent daily cisplatin
or carboplatin with conventional radiotherapy, or
alternating split-course radiotherapy with cisplatin
plus infusional 5-fluorouracil.
3. METHODS AND RESULTS
3.1 Part 1: The Clinical Study
The methods and results of a population-based study of
all patients with squamous cell cancer of the oropharynx
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treated in Ontario during 20032004 have previously
been published19. The study used information from the
population-based Ontario Cancer Registry located at the
Division of Cancer Care and Epidemiology (formerly
the Radiation Oncology Research Unit) of the Queens
Cancer Research Institute. All potential patients were
identified based on International Classification of Dis-
eases codes with a date of diagnosis between January
1, 2003, and December 31, 2004. The outpatient charts,
with treatment records, were reviewed by experienced
abstractors at the Queens Cancer Research Institute for
data on patient characteristics, extent of disease, inves-
tigations, treatments, and outcomes. After exclusions,
571 cases of oropharyngeal carcinoma were retained.
Patient variables included the Adult Comorbidity
Evaluation20 and staging according to the TNM clas-
sification (6th edition)21. Patient status with respect to
the human papilloma virus (hpv) was not available. We
defined four initial treatment options of radiotherapy
(rt), chemoradiotherapy (ccrt), surgery, or palliation,
including treatment of residual disease (because that
would be assumed to be part of the initially planned
treatment). The surgery cohort included patients who
received planned postoperative rt. The palliation cohort
was identified based on a statement of intent in the
chart for palliative or no treatment, regardless of the
actual treatment administered. We recorded the cancer
treatment centre at which the initial treatment was per-
formed, and all centres were anonymized for analysis.
Using the percentage of patients receiving ccrt at each
centre, we compared outcomes at cancer treatment
centres with similar protocols and stratified the centres
based on a cut-point of 50% into those with higher
and lower use of ccrt. Survival outcomes for the two
groups were compared by the KaplanMeier method
and Cox proportional hazards regression, controlling
for age, sex, comorbidity, sub-site, Tstage, and Nstage.
Tablei describes the patient population. Treat-
ment selection was evident in the data: overall, the
patients receiving ccrt were younger and healthier,
with more advanced disease and a higher rate of base-
of-tongue cancers. In comparing patients managed at
the 9 treatment centres, we observed no statistically
significant difference in age (p= 0.87), comorbidities
(p= 0.39), sub-site (p= 0.65), Nstage (p= 0.19), or
TNM group (p= 0.22).
Table ii presents the initial treatments. More
than 85% of the patients were treated with either rt
or ccrt, but there was little agreement or consensus
about treatment among the 9 centres (p< 0.0001).
Although approximately 10% of patients at all centres
received palliative treatment, the rate of ccrt varied
from 78.26% to 30.14% (p< 0.0001). When patients
receiving palliation and surgery were excluded,
variation in the use of ccrt ranged from 82% to 39%
(Figure1).
Tableiii presents the six chemotherapy regimens
used in the study population. In the centre compari-
son presented in Figure2, the regimens are grouped
 VARIATION IN UPTAKE OF A GUIDELINE IN HEAD-AND-NECK CANCER

table i Patient and tumour characteristicsa table ii Initial treatments delivered at the nine centresa

Characteristic Value Treatment Value

(n) (%) (n) (%)

Sex Radiotherapy 235 41.2

Men 434 76.01 Chemoradiotherapy 256 44.8
Women 137 23.99 Surgery 14 2.5
Age
Palliative or no treatment 66 11.5
<50 Years 113 19.79
TOTAL 571
5059 Years 180 31.52
6069 Years 139 24.34 a Adapted from Hall et al.19 with permission from
7079 Years 116 20.32 WileyBlackwell.
80 Years 23 4.03
ace-27 score

0 224 39.23
1 180 31.52
2 106 18.56
3 61 10.68
Cancer site
Base of tongue 197 34.50
Faucial arch 345 60.42
Other 29 5.08
Histologic grade
i /ii b 269 47.1
iii /ivc 164 28.7
Missing 138 24.2
Primary tumour
T1 130 22.77
figure 1 Patients treated with radiotherapy (rt) or concurrent
T2 205 35.90 chemotherapy and radiotherapy (ccrt), by treatment centre (anony-
T3 100 17.51 mized). Excludes palliative and primary surgery cohorts. Adapted
T4 136 23.82 from Hall et al.19 with permission from WileyBlackwell.
Lymph nodes
N0 130 22.77
N1 97 16.99 table iii Chemotherapy regimens used at the nine centresa
N2a 49 8.58 Drug Regimen Value
N2b 158 27.67
N2c 114 19.96 (n) (%)
N3 23 4.03 Cisplatin Daily 82 32.0
Metastasis Weekly 24 9.4
M0/Mx 555 97.20 Every 3 weeks 110 42.9
M1 16 2.80
TNM stage Carboplatin Daily 2 0.7
i /ii 82 14.36 Weekly 20 7.8
iii 101 17.69
5fu combinations 18 7.0
iv 388 67.95
a Adapted from Hall et al.19 with permission from TOTAL 256
WileyBlackwell.
b Well or moderately differentiated. a Adapted from Hall et al.19with permission from
c Poorly differentiated or undifferentiated. WileyBlackwell.
ace-27= Adult Comorbidity Evaluation. 5fu= 5-fluorouracil.

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 HALL et al.
figure 2 Chemotherapy regimens used, by treatment centre (ano-
nymized). 5fu= 5-fluorouracil; q3= every three.
into 4 classes of therapy (low-dose daily cisplatin
or carboplatin, mid-dose weekly, high-dose every 3
weeks, and any combination with 5-fluorouracil). In
5 centres, one regimen (that aligned with the cpg) was
used almost exclusively. In 2 centres, two primary
regimens (one of which did not align with the cpg)
were used. In 1 centre, all four chemotherapy options
were tried during the 2 years of interest.
In comparing the outcomes of all patients and of
those treated at the centres with higher and lower
use of ccrt, we observed no difference in 3-year over-
all survival (66.8% vs. 66%), 5-year overall survival
(58.8% vs. 57.5%), 3-year disease-specific survival
(72.3% vs. 72.5%), and 5-year disease-specific sur-
vival (68.9% vs. 67.7%) (Figure3). The hazard ratio
in the Cox model was 1.028 (95% confidence interval:
0.775 to 1.363; p= 0.85).
3.2 Part 2: Knowledge Transfer
The cpg process and the guideline itself provided in-
formation about randomized trials and meta-analyses
about ccrt regimens up to 2000 for oncologists in
Ontario, but other sources of information such as
journal articles and presentations at major meet-
ings were available to clinicians. A medline search
spanning 1950 to the present combined the key word
head and neck neoplasms with combined modal-
ity therapy (mesh) and each of the following phrases
as text words: concomitant or combined, radio-
therapy, chemotherapy, radiochemotherapy, and
chemoradiotherapy. The reference lists of relevant
studies were used to identify additional publications.
To address the emergence of high-dose regimens,
the foregoing terms were then combined with the
search term high dose. We tabulated the number of
publications describing only high-dose concomitant
ccrt schedules between January 1997 and December
2003, because those publications might have influ-
enced oncologists in Ontario.
Presentations at major meetings are another source
of information for clinicians, especially if the presen-
tations are given by opinion leaders. The American
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figure 3 Disease-specific survival of patients treated at centres
with higher and lower use of concurrent chemotherapy and radio-
therapy.
Society of Clinical Oncology Web site (http://www.
asco.org) and the American Society for Radiation
Oncology Web site (http://www.oncolink.org) were
searched for relevant conference proceedings from
meetings during 19972003 of head-and-neck poster
or oral presentations describing high- and low-dose
ccrt administered for head-and-neck cancer. Unfortu-
nately, programs and abstracts for the annual meetings
of the Canadian Association of Medical Oncologists
and the Canadian Association of Radiation Oncology
during the same period were not available online. For
the present review, only podium presentations of high-
dose ccrt regimens for head-and-neck cancer were
included. However, we classified posters (American
Society of Clinical Oncology head-and-neck and
central nervous system group, 19981999; and head-
and-neck cancer group, 20002003) as high-dose,
low- or medium-dose, or any ccrt schedule.
Tableiv shows the numbers of manuscripts, pre-
sentations, and posters that were located during the
search. Over time, the number of published manu-
scripts about high-dose regimens remained constant.
The number of posters on ccrt presented each year
increased, and the number of posters on high-dose
and low- or mid-dose regimens held steady. However,
between 2000 and 2002, 14 podium presentations
about high-dose regimens were delivered; few such
presentations were delivered before 2000, and one
was delivered in 2003.
4. DISCUSSION
Given the resources and time required to follow the
cpg development cycle and to create a cpg15, adherence
ought to be high. Typically, adherence in Ontario to
the cgps created by cco is high22. However, the pres-
ent study demonstrates that 24 years after approval
of a guideline, adherence was mixed and much lower.
The 9 Ontario cancer treatment centres used ccrt for
55% of oropharynx cancer patients overall (range:
30%80%), and although not all patients would have
 VARIATION IN UPTAKE OF A GUIDELINE IN HEAD-AND-NECK CANCER

table iv Publications, podium presentations, and posters about chemoradiotherapy, high-dose chemoradiotherapy, and lower-dose che-
motherapy for head-and-neck cancer, 1997 to 2003

Forum Topic Year

1997 1998 1999 2000 2001 2002 2003

Publication High-dose chemoradiotherapy 17 8 8 10 9 9 8

Podium presentationa High-dose chemoradiotherapy (astro) na na 0/44 0/33 4/63 3/54 0/32
High-dose chemoradiotherapy (asco) na 0/23 0/31 2/32 3/67 2/56 1/58

Poster Chemoradiotherapy (asco) 21/101 25/120 40/92 39/85 44/100 34/74 42/101
High-dose chemoradiotherapy (asco) 12/101 13/120 14/92 13/85 18/100 19/74b 18/101c
Low- or mid-dose chemoradiotherapy (asco) 3/101 4/120 15/92 13/85 13/100 7/74d 13/101e
a Denominator indicates the total number of key podium presentations at the meeting.
b Includes 10 selected oral presentations.
c Includes 13 selected oral presentations.
d Includes 3 selected oral presentations.
e Includes 10 selected oral presentations.

astro= American Society for Radiation Oncology; asco= American Society of Clinical Oncology; na= information not available online.

been eligible for ccrt, we observed little difference in
patient characteristics between centres. Furthermore,
no agreement on the drug regimen was evident: 4 cen-
tres were following the guideline for most patients, 2
centres were following the guideline for some patients,
and 3 centres were using regimens not supported by
the guideline.
Cabana et al.23 cited 7 reasons why physicians
do not follow guidelines, including lack of aware-
ness, lack of familiarity, lack of agreement with the
evidence, lack of outcome expectancy, lack of self-
efficacy, inertia of previous practice, and external
barriers. The reason for the varied uptake of ccrt in
Ontario might have been lack of agreement with the
evidence (despite the practitioner feedback process),
external barriers, or the inertia of previous practice.
However, why were 3 centres exclusively using a
high-dose regimen that was not recommended in the
cpg? In Tableiv, the data show continued interest in
ccrt whether high- or low-dose, but the number of
podium presentations on the new high-dose regi-
mens at major meetings was increasing. It could be
that some Ontario centres were influenced by those
presentations more than by the cpg (noting that there
had not beenand never has beena clinical trial
comparing the high- and low-dose regimens).
The development of the 5-6a cpg carefully fol-
lowed the steps of the guideline development cycle15
used in 2000 and almost certainly would have satisfied
all the criteria of the newer agree tools for creating or
assessing guidelines (http://www.agreetrust.org/)24.
Why, then, did adherence vary?
First, for a new guideline to be accepted by groups
and organizations, the process ought to address the
culture and receptivity of the physicians and organiza-
tions the guideline is intended to influence. The new
cgp, together with the momentum of the ccrt revolu-
tion of that time, was led by medical oncologists at
a time when the head-and-neck teams, site groups,
tumour boards, and management care conferences
were traditionally staffed by radiation oncologists and
surgeons. The role of medical oncology in head-and-
neck cancer was limited to palliative care or research
within approved clinical trialsbecause, aside from
a U.S. Veterans Affairs trial25, chemotherapy had not
been showing much progress or promise. Although
the medical oncology community was no doubt en-
thusiastic, acceptance by the radiation oncologists
and head-and-neck surgeons almost certainly varied
depending on institutional practices.
At the institution level, the political landscape
can also be a factor in adherence to any new guide-
line, and interestingly, in 2000, cco had approved
divestment of the provision of cancer care services
at Ontario cancer treatment centres to the hospitals
hosting the regional centres, a process that was
completed in 2002. That change coincided with
production of the guideline, and it is possible that
the head-and-neck site groups at the host hospitals
did not feel as responsible to cco-created cpgs once
the line of responsibility had changed.
A second potential reason for varied adherence is
acceptance of the opinions of the guideline develop-
ment committee. The committee members ought to
be representative of the potential target physicians
and familiar with the process. The committee at that
time (2000) consisted of volunteer members from
some specialties at each cancer treatment centre
whose opinions might or might not have reflected the
opinions of other members of the local head-and-neck
treatment team. The chair at the time was very knowl-
edgeable about the cpg development cycle, but many

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e65
 HALL et al.
members of the Head and Neck Cancer Disease Site
Group were experiencing their first encounter with
the complex and prolonged evidence-based guideline
process. The newness of the process almost certainly
slowed the process in a clinical environment that was
continuing to evolve.
A third reason for varied adherence is the need
to address major concerns or potential concerns.
In 2000, ccrt was a very controversial treatment,
and very real concern was being expressed by most
head-and-neck teams about the validity of the data on
late toxicity8,9, especially permanent dysphagia1013.
Based on a review of the clinical trials, one author 9
had even stated that no data were collected on the
critical items of swallowing and airway function.
These gaps, inconsistencies and variations in report-
ing practices indicate that published toxicity reports
are not only frequently lacking key information,
but also suggest that they likely contain significant
underreporting, bias and errors. It is not surprising
that the enthusiasm of physicians and centres varied.
Addressing concerns might also require the inclusion
of competing evidence and, in this case, evidence
about other non-chemotherapy options. Published
trials had reported that, compared with conventional
rt, hyperfractionated rt without chemotherapy was
associated with better outcomes26, and some rt
departments in Ontario were particularly interested
in that treatment option. The cpg meta-analysis had
included two studies on hyperfractionation, but did
not directly compare hyperfractionated regimens
with ccrt regimens; and although the statement the
data for concomitant chemoradiotherapy are at least
as good as the data for accelerated fractionation the
body of evidence is higher appears in the discussion,
it does not appear in the recommendations. The use
of hyperfractionated rt with an increased total dose
was subsequently shown to provide an effect (8% dif-
ference with a 22% reduction in the hazard of death)
identical to that achieved with ccrt27,28.
A fourth potential reason for varying adherence
is that a guideline might be an inappropriate approach
for controversial topics with an evidence base that
is rapidly expanding and evolving. By the time this
particular cpg was published, the recommendations
were clearly considered historical by some centres.
A looser or more fluid statementwith some combi-
nation of evidence updates, ongoing review, or reas-
sessment of the recommendationswould perhaps
have provided more and better information to the
head-and-neck oncologists of Ontario.
A final reason for varied uptake is the lack of
a mechanism for feedback (Smith and Hillner29).
Given the controversy concerning the guideline, a
built-in mechanism for direct feedback to or an audit
on uptake after 12 years might have proved useful
for the Head and Neck Cancer Disease Site Group,
the Program in Evidence-Based Care, the guideline,
and physicians.
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To summarize, the observed variation in adher-
ence was likely attributable to receptivity, the pro-
cess, new evidence with new treatments, a lack of
feedback, and concern over incomplete data.
Figure3 further complicates the story: Our re-
sults suggest that the addition of chemotherapy to rt
had a minimal effect on survival for oropharyngeal
cancer patients in 20032004. The complete analysis
has already been reported19. In our study, the univari-
able and multivariable analyses might be confounded
by hpv status (although the effect of hpv status was
not known at the time of the guideline); however, it is
unlikely that the rate of hpv-positive cases varied in
the populations of the higher-use and lower-use
centres in our study. Our findings have two possible
explanations: either the evidence about ccrt for
oropharyngeal cancer was not, outside the biases of
the clinical trials, generalizable to the real world of
community practice in the 9 Ontario cancer treat-
ment centres30, or the evidentiary base concerning
the addition of chemotherapy to rt for head-and-neck
cancer was confounded by the evolving causative role
of hpv. Clinical trials and population-based studies
are under way to answer that fundamental question.
A review of the extensive literature on com-
pliance with or adherence to cpgs is beyond the
scope of this report; review articles by Smith and
Hillner29, Francke et al.31, Grimshaw and various
colleagues2,3,32, and Tan33 are recommended. Three
previous studies on compliance with cpgs specifi-
cally in head-and-neck oncology (including thyroid
cancer) have been published.
Van Agthoven et al.34 compared practice based
on chart reviews before and after a guideline on the
diagnosis, treatment, and follow-up of patients with
laryngeal cancer in the Netherlands. Those authors
reported that in general, the guideline recommenda-
tions were properly complied with and that compli-
ance was related to the quality of the evidence. They
noted that a plan for direct feedback on performance
to clinicians and some form of accountability as pro-
posed by Smith and Hillner29 might have improved
their results and, subsequently, the quality of the
guideline. The cco 5-6a guideline would have been
improved by some form of built-in feedback, espe-
cially given that treatments were evolving.
Another relevant adherence study was reported
by Lewis et al.35, based on a chart review of 107 new
patients referred with recurrent or residual head-and-
neck cancer to the MD Anderson Cancer Center.
Using the U.S. National Comprehensive Cancer
Network head-and-neck guidelines as a compara-
tor, those authors found that 58.7% of the patients
had received inadequate surgery; 10.9%, inadequate
adjuvant therapy; and 4.4%, inadequate rt.
Panigrahi et al.36 compared prior clinical prac-
tice with a guideline on the treatment of medullary
thyroid cancer that had undergone many iterations
over time. Based on data for 2033 patients from the
 VARIATION IN UPTAKE OF A GUIDELINE IN HEAD-AND-NECK CANCER
U.S. Surveillance, Epidemiology and End Results
database, those authors found that the extent of
surgery was inappropriate in 41% of cases. They
identified differences by geographic region, year of
treatment, tumour size, age, and sex as contributing
factors. Our study found regional differences in ad-
herence, and the guideline might not have improved
survival outcomes.
5. CONCLUSIONS
By 3 years after publication, the recommendation
of the cco cpg on the use of ccrt over rt alone for
patients with advanced squamous cell cancers of the
head-and-neck was adopted for 55% of patients with
oropharyngeal cancer across Ontario; however, the
uptake by centre varied from 82% to 39%, possibly
because of concerns about evidence quality, medical
culture, delay in process, and evolving treatment op-
tions not addressed in the guideline. The drug regi-
men recommendation was modified by many centres
(possibly on the basis of presentations by opinion
leaders) in the period immediately after publication of
the cpg, despite no comparative evidence being avail-
able. Clinical practice guidelines ought to include a
more precise estimate of adherence, performance
ought to be frequently monitored when the guideline
is controversial, and a more fluid guideline format
might be more appropriate in situations in which the
evidence is evolving rapidly.
6. ACKNOWLEDGMENTS
The research proposal titled The impact of the On-
tario Clinical Practice Guideline #5-6a on physicians,
patients and practice was funded (no.19174) by the
ncic (now the Canadian Cancer Society Research
Institute). The project was approved by the Research
Ethics Board of Queens University (OTL-028-06)
and also by all Ontario cancer treatment centre host
hospitals. Use of the data was approved by both the
Ontario Cancer Registry and cco. The joint study
coordinators at the Division of Cancer Care and
Epidemiology were Tina Dyer and SR, with assistant
Sarah Pickett. The statistician/analysts were Rebecca
Griffiths and Diana Martins. SFH was responsible
for grant application, data collection, data analysis,
and manuscript preparation. Dr. Melissa Brouwers
kindly assisted with early versions of the manuscript.
Portions of this work (Should guideline review
include assessment of adherence?) were presented
at the 4th Guidelines International Network Confer-
ence; Toronto, Ontario; August 2225, 2007.
7. CONFLICT OF INTEREST DISCLOSURES
We have read and understood Current Oncologys
policy on disclosing conflicts of interest, and we
declare that we have none.
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Correspondence to: Stephen F. Hall, Division of
Cancer Care and Epidemiology, 10Stuart Street,
Kingston, Ontario K7L3N6.
E-mail: sfh@queensu.ca
* Department of Otolaryngology, Queens University,
Kingston, ON.
 Division of Cancer Care and Epidemiology,
Queens University, Kingston, ON.
 Department of Surgical Oncology, Princess
Margaret Cancer Centre, University of Toronto,
Toronto, ON.
 Department of Oncology, Queens University,
Kingston, ON.
|| Division of Cancer Care and Epidemiology,
Queens University, Kingston, ON.