Clinical Guidelines have a Self-Fulfilling loop! They are developed by the very clinicians who then follow them!
Here is my piece on clinical guidelines in general, and a bit on ethics and the like! I hope it helps!
Yes, guidelines are developed by those who then go on to use them. The idea is to put in writing, a method that seems to work best, and is backed by evidence. Its a standardisation process (to reduce excessive variation).
The endorsement from a professional college or other professional societies is just a confirmation that the guideline has been developed from within a recognised structure and oversight, with key processes having been followed, including things like peer review by members of that group, etc.
Also, importantly, most guidelines are actually first developed at the local level! A local guideline then becomes the tool that leads to a spread of practice, to a point where that practice becomes national, and beyond! I hope you can all see what that means.
On an absence of a drug from clinical guidelines: this may indicate something about the drug itself - such as insufficient evidence of benefit, lack of awareness, or concerns about adverse effects. Alternatively, it might reflect a more fundamental issue - a lack of convincing evidence that the issue the drug aims to address is significant enough to warrant an additional treatment. On the latter: the growing realisation of cardiotoxicity (as is happening) should help drive this change. It is for society to decide when an ISSUE they have lived with, has become a PROBLEM for them!
While doxorubicin’s cardiotoxicity is well established, it may be that the effectiveness of available preventative treatments might still be debated (I dont know for sure). Lets ask ourselves: if an effective drug were available and its benefits widely accepted, would clinicians spend time exploring the kind of alternatives like hospital-based exercise programs, as some studies suggest is being done? Exercise is good, but its effects are too imprecise to be incorporated into clinical care - particularly in cancer, where the patients are already frail at diagnosis.
Yes, accelerated aging happens even before and without chemotherapy: there is cancer induced accelerated aging, and there is chemotherapy induced accelerated aging! They are separate issues with different as well as shared mechanisms of development! Does Bisantrene work in both? We will know more once the publication drops, I guess[I hope it does. That way, it may still be valuable even when its cancer killing effect is not as huge - in combination with more potent drug!s as well as radiation therapy.]
Medical practice evolves over time as evidence accumulates. Cardio-Oncology is itself still a new subspecialty, so RAC seems to be in the right place at the right time. A bit of noise about the PROBLEM will help, particularly once a therapy has been confirmed. Aaron has a job ahead of him: Opinion leaders play a really crucial role in shaping clinical practice and pushing good care. Lets hope he is up to it! The expectation has to be that the first clinical guideline to incorporate Bisantrene will come from his team!
RAC certainly has good scientists and is producing good science, but that alone will not be enough to get the drug used: the science needs translation. Clinicians will need to be told about this mature drug that has revealed its hidden superpowers!
Not many clinicians read the so called High Impact journals like Nature: it’s not a practical use of their time. Those articles rarely make it to journal club discussions. Journals that are closer to the shop floor, such as The Lancet, BMJ, and JAMA, as well as college-owned or sponsored publications with no formal impact factor at all, drive changes in everyday practice more effectively. [I support the High Impact journal for now - it will draw academics and scientists, and create a lot more citations - apart from giving the authors some serious recognition.]
Also, Clinicians don’t just stumble upon new treatments by chance! Someone must introduce the drug to them, and then word spreads. This is one of the areas where the drug company must do some work in promoting their drug: conferences, and hospital visits where its permitted. Investigator Initiated trials too! In the US - billboards are allowed.
A question may also be asked of the supposed poor adoption of the existing therapies for this problem: 'Have the therapies been promoted by the drug manufacturers?' If not, why?
There is a video on the RAC YouTube channel by Dr Ron Hargreaves on 'The Early development of Bisantrene' (shared below) - he says "Lerdele NEVER MARKETED Bisantrene" after it was approved in France. It's not enough to say - we have an appproval! We have seen how Telix and MSB have invested quite heavily in marketing their drugs!
On some of the concerns raised: People should be reassured that Clinicians are driven by ethics; if a drug is beneficial, and they get to know about it, they will actually look for it. That is how the drug may then make its way into guidelines, which by the way. It is always the drug first (with its evidence), before a guideline gets developed, or if one already exists, the drug gets incorporated into it. And within that, you get 1st line, 2nd line, etc. That's how Best in Class works its way up. Clinicians gain nothing from being negligent!
DISCLAIMER (of sorts)! This writeup is mostly influenced by healthcare systems that are designed with a focus on providing public good (like the UK's NHS, as well as the Medicare funded Australia, and NZ' public system). This is in contrast to the profit focussed models used in the US (or Australia's Private care), where even in conferences meant to discuss evidence based care, its not uncommon to hear a presenter saying, "in MY practice, I use drug X and Y for problem Z, and it works well for MY patients!"
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