Adequacy of clinical guideline recommendations for patients with low-risk cancer managed with monitoring: systematic review

Objective The aim of this systematic review was to summarise national and international guidelines that made recommendations for monitoring patients diagnosed with low-risk cancer. It appraised the quality of guidelines and determined whether the guidelines adequately identified patients for monitoring, specified which tests to use, defined monitoring intervals, and stated triggers for further intervention. It then assessed the evidence to support each recommendation. Study Design and Setting Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses, we searched PubMed and TRIP databases for national and international guidelines' that were written in English and developed or updated between 2012-2023. Quality of individual guidelines was assessed using the AGREE II tool. Results Across the 41 published guidelines, 48 different recommendations were identified: 15 (31%) for prostate cancer, 11 (23%) for renal cancer, 6 (12.5%) for thyroid cancer and 10 (21%) for blood cancer. The remaining 6 (12.5%) were for brain, gastrointestinal, oral cavity, bone and PPGL cancer. When combining all guidelines, 48 (100%) stated which patients qualify for monitoring, 31 (65%) specified which tests to use, 25 (52%) provided recommendations for surveillance intervals, and 23 (48%) outlined triggers to initiate intervention. Across all cancer sites, there was a strong positive trend with higher levels of evidence being associated with an increased likelihood of a recommendation being specific (p = 0.001) and the evidence for intervals was based on expert opinion or other guidance. Conclusion With the exception of prostate cancer, the evidence base for monitoring low-risk cancer is weak and consequently recommendations in clinical guidelines are inconsistent. There is a lack of direct evidence to support monitoring recommendations in the literature making guideline developers reliant on expert opinion, alternative guidelines, or indirect or non-specific evidence.