To Oncology

Emily DeVoto and Barnett S. Kramer*

In the early years of the 21st century, clinicians and medical researchers often use the term evidence-based medicine. Cancer prevention, screening, diagnosis, and therapy, we hear, must be based on the best evidence to provide the best care. But is this approach new? And if it is, what have we been doing until now? In this chapter, we hope to provide perspectives on this question, by examining what evidence-based medicine (EBM)—oncology, in particular—is and is not, and by looking at the history of clinical inquiry, up to and including current research. We also hope to provide readers with a theoretical framework that will be useful in placing the results of new research into the context of existing knowledge, with the ultimate goal of improving clinical practice.

The principles of EBM were delineated by a working group in Canada (led by Gordon Guyatt of McMaster University) and published in JAMA in 1992.1 According to Sackett and colleagues, some of the earliest promoters of the principles of the concept, EBM is "the integration of best research evidence with clinical expertise and patient values."2 Thus, EBM is not cookbook practice performed by technicians without regard to experience, training, or independent clinical judgment. The practice of EBM has occurred with the recognition that up-to-date, scientifically valid medical information is needed on a regular basis; that traditional sources of information (such as textbooks, expert opinion, and the flood of new research) are either unreliable or overwhelming; and that patient and other demands limit clinicians' time available for keeping skills current and for identifying the most relevant information. In response, medicine has developed strategies and information systems for tracking down useful information quickly and mechanisms for stringent, systematic review and evaluation of clinical research.2 The purpose of textbooks such as this, and other forums for EBM, is to empower practicing clinicians with the skills to evaluate the literature, to identify relevant clinical guidelines and recommendations, and to understand the study design factors that affect the quality of medical evidence, in support of sound clinical decision making.

Sackett and colleagues propose the following five steps for clinicians in making evidence-based decisions: "(1) Converting the need for information into an answerable question; (2)

*The opinions expressed in this manuscript are those of the authors and do not represent official opinions or positions of the National Institutes of Health, the Department of Health and Human Services, or the federal government.

Tracking down the best evidence to answer the question; (3) Critically evaluating that evidence; (4) Integrating the critical evaluation with clinical expertise and knowledge of the patient; (5) Evaluating our effectiveness and efficiency in steps 1 to 4 and seeking ways to improve both for next time."2 Later in this chapter, we elaborate on these steps to provide a practical framework for clinical decision making. First, however, we attempt to place the development of the concept of medical evidence in a historical context, focusing on aspects of research that point to quality of evidence.

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