NEW AUSTRALIAN GUIDELINES

FOR THE DIAGNOSIS AND CLINICAL MANAGEMENT

OF MELANOMA (USING CANCER COUNCIL AUSTRALIA’S WIKI PLATFORM)

John Thompson Professor of Melanoma and Surgical Oncology, The University of Sydney

Executive Director, Melanoma Institute Australia

Australasian Melanoma Conference 2016 28 – 29 October, 2016

Sofitel Wentworth, Sydney

WHY HAVE GUIDELINES?

The purpose of guidelines in health care is : - to make it more likely that patients will

receive appropriate advice and treatment - so that the recommendations and treatment

will be based on the best available evidence

PROBLEMS ASSOCIATED WITH WRITTEN GUIDELINES

• Out of date even when first published because of new evidence constantly becoming available

• Non-automated electronic searching of bibliographic databases is expensive and time consuming

• Wide stakeholder consultation is

important but adds to the delay in publication

AUSTRALIAN MELANOMA GUIDELINES REVISION

• By 2014 it was clear that revision of the 2008 national Melanoma Management Guidelines was required

• Cancer Council Australia (CCA) and Melanoma Institute Australia (MIA) agreed to undertake the revision (JFT to chair Management Committee and Working Party)

• • MIA and CCA provided resources

• CCA’s wiki guideline development platform to be used

• Infrastructure in place to continually update

AUSTRALIAN MELANOMA GUIDELINES REVISION

• First Management Committee meeting Nov 2014

• Agreement on list of questions to be revised

• Establishment of working party & question sub-committees

• Prioritisation of questions

• March 2015 - systematic reviews commenced

DETAILED OVERVIEW: QUESTION PROGRESS

DETAILED OVERVIEW (CONTINUED)

DETAILED OVERVIEW (CONTINUED)

AUSTRALIAN MELANOMA GUIDELINES REVISION

• In July 2015 Skin Cancer College Australasia joined

the project and provided funding for an additional

Project Officer to help conduct systematic reviews

and complete the guideline revision faster

Ongoing literature feed

Ongoing appraisal of

literature

Ongoing content updates

Content additions

where needed

Ongoing commenting

THE WIKI PROCESS FOR PRODUCING GUIDELINES

2) Develop clinical questions

3) Develop search strategy, systematically search the literature & feed into wiki

4) Critically appraise and summarise the literature on the wiki

5) Assess body of evidence, formulate recommendations, write content

6) “Wiki-fication” of content & dissemination

1) Establish WP party and guideline objectives

SYSTEMATIC REVIEW PROCESS INVOLVES A NUMBER OF PRESCRIBED STEPS AIMED AT ELIMINATING BIAS

• Define question - PICO format: P=Population, I=Intervention,

C=Comparison, O=Outcomes

• Pre-specify inclusion/exclusion criteria (including eligible study design)

• Search all relevant databases for potentially relevant articles

• Apply inclusion criteria and assess risk of bias

• Use Evidence Statement template to synthesise evidence by assessing :

Volume, level of evidence, quality, consistency, clinical impact,

generalisability, applicability

FINALLY - Produce evidence statements and graded recommendations

TRANSLATION OF CLINICAL QUESTION TO PICO TABLE Clinical question:What is the role of dermoscopy (and sequential dermoscopy) in melanoma diagnosis?

Population Intervention Comparator Outcome Study design All people

Dermoscopy

Sequential dermoscopy (SDDI)

Naked Eye Examination

Physical Examination

Differential Diagnosis

Diagnostic accuracy

Sensitivity

Specificity

Positive Predictive Value

Negative Predictive Value

Excision of benign lesion rates

Benign to malignant ratios

Meta-analysis

Systematic reviews

RCTs (of diagnostic studies)

Diagnostic accuracy studies

Prospective studies

Retrospective studies

Comparative studies All people Automated Instruments

Naked Eye Examination Dermoscopy

Diagnostic accuracy Sensitivity Specificity

SYSTEMATIC LITERATURE SEARCH & RESULTS SCREENING

ASSESSING LITERATURE ONLINE

THE WIKI WAY: EVALUATING EACH PAPER

EVIDENCE TABLE

LITERATURE SEARCH SUMMARY

DEVELOPING CONTENT

RECOMMENDATION TYPES (BASED ON NHMRC GUIDELINES)

A. Evidence-based recommendations

– Recommendations formulated by the guideline development group based on a systematic review of quality evidence and graded according to an NHMRC-approved method.

B. Consensus-based recommendations

– Recommendations formulated by the guideline development group, using a consensus-reaching process, when a systematic review was undertaken and insufficient quality evidence was found on which to base a recommendation.

•

RECOMMENDATION TYPES

C. Practice points

– Points of guidance included in the guideline used to support

evidence-based recommendations where the subject matter is

outside of the scope of the systematic review, and which were

formulated based on expert opinion using a consensus process

– Recommendations where the subject matter is not addressed by the

clinical questions.

REVISION OF AUSTRALIAN MELANOMA MANAGEMENT GUIDELINES

PROGRESS TO DATE (OCTOBER 2016)

• Finalised content for 3 systematic review and 1 background question

• Draft content for another 3 questions to be

released for consultation in the early 2017

• 5 systematic reviews in progress

ACCESS TO GUIDELINES

• To access the finalised guidelines:

wiki.cancer.org.au/Australia/Guidelines:Melanoma

• To be notified about updates to the guidelines:

Email guidelines@cancer.org.au