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Guideline Summary
Guideline Title
Psychosocial health care for cancer patients and their families.
Bibliographic Source(s)
Turnbull G, Baldassarre F, Brown P, Hatton-Bauer J, Li M, Lebel S, Durkin L, Green E, Psychosocial Oncology Expert Panel. Psychosocial health care for cancer patients and their families. Toronto (ON): Cancer Care Ontario (CCO); 2010 Oct 12. 65 p. (Evidence-based series; no. 19-3).  [134 references]
Guideline Status

This is the current release of the guideline.

The EVIDENCE-BASED SERIES report, initially the full original Guideline, over time will expand to contain new information emerging from their reviewing and updating activities.

Please visit the Cancer Care Ontario Web site External Web Site Policy for details on any new evidence that has emerged and implications to the guidelines.

Scope

Disease/Condition(s)

Psychosocial health in patients with cancer

Guideline Category
Management
Clinical Specialty
Family Practice
Internal Medicine
Oncology
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Dietitians
Health Care Providers
Nurses
Occupational Therapists
Other
Physical Therapists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers
Speech-Language Pathologists
Guideline Objective(s)
  • To create a psychosocial care framework that can be used to direct improvements in the quality of comprehensive cancer care for patients and their families in Ontario
  • To provide recommendations on the best strategies for meeting the psychosocial health care needs of cancer patients and their families at both the provider level (psychosocial health services) and the system level (psychosocial health intervention)
Target Population

Adult cancer patients and their families

Interventions and Practices Considered
  1. Understanding and defining psychosocial care
  2. Ensuring provision of appropriate psychosocial health services
    • Facilitating effective communication
    • Identifying psychosocial health needs
    • Designing and implementing a plan
    • Systematically monitoring, evaluating, and readjusting plans, as needed
  3. Ensuring all health care providers have training to provide patients and families psychosocial standard of care
  4. Providing patient and family education
  5. Creating mechanisms to measure and report on quality of psychosocial health care
  6. Ensuring workforce competencies
  7. Standardizing nomenclature
  8. Sponsoring psychosocial research
Major Outcomes Considered
  • Functional status
  • Adherence to therapies
  • Ability to work
  • Morbidity and mortality

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Description of Methods Used to Collect/Select the Evidence

The 2008 Institute of Medicine (IOM) standard Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs served as a foundation document upon which the Group created the framework and recommendations. The IOM document was chosen for its comprehensive coverage, quality, currency, content, and consistency.

Number of Source Documents

One Institute of Medicine (IOM) document was used to create the framework and recommendations.

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

The Working Group agreed that the Institute of Medicine (IOM) standard document was such that it could be recommended for adaptation in Ontario, because of its overall quality, currency and consistency, acceptability, and applicability. The detailed results of the assessment of content and consistency, currency, and validity of the IOM document, performed using the ADAPTE process, along with a brief summary of the supporting evidence gathered by the IOM Committee and the tools used during the adaptation process (http://www.adapte.org/ External Web Site Policy) are presented in Appendix 2 (A) in the original guideline document. Appendix 2 (B) in the original guideline document presents considerations about the acceptability and adaptability of each of the IOM recommendations to Ontario, and Appendix 2 (C) in the original guideline documents reports the results of the quality assessment performed on the IOM document using The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (http://www.agreetrust.org/ External Web Site Policy).

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

A team comprised of experts in psychosocial oncology care and research methodologists was assembled at the start of the project (see Appendix 1 in the original guideline document). The Practice Guidelines Development Cycle and the ADAPTE process were the key methodological strategies used to create this document.

First, the ADAPTE process was used to adapt the recommendations provided in the Institute of Medicine (IOM) standard document to Ontario. The ADAPTE process is a systematic approach to the adaptation of guidelines produced in one context for use in another context (http://www.adapte.org/ External Web Site Policy). The adaptation process involves three phases: A set-up phase, an adaptation phase, and a finalization phase. During the initial set-up phase the topic was selected, the necessary skills and resources were identified, the Psychosocial Oncology Working Group was established, the IOM document was selected for review, and feasibility for adaptation was assessed. Once the set up phase was completed, the Working Group assessed the IOM document for quality, currency, content, and consistency. Four members of the Working Group: a clinician, a manager, and two methodologists from the Program for Evidence-based Care (PEBC), evaluated the quality of the IOM standard using the AGREE instrument (also available at http://www.agreetrust.org/ External Web Site Policy). The AGREE instrument consists of 23 items organized in six domains that capture guideline quality. The six domains include: scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, and editorial independence. Each item is rated on a 4-point scale described as: 4 = strongly agree, 3 = agree, 2 = disagree, and 1 = strongly disagree. A section for overall assessment is included at the end and provides the opportunity to make a judgement on the overall quality of the document. Inter-rater differences of more than one point were addressed among the group to achieve overall consensus. All members of the Working Group met and determined currency, content, and consistency of the IOM document. In order to check for currency, the developers of the IOM document were contacted, and the original search strategies were obtained. Consistency and content were evaluated with a series of questions which are part of the ADAPTE process. Finally, the Working Group assessed the acceptability and the applicability to Ontario of each one of the 10 recommendations presented in the IOM document according to the series of questions which are part of the ADAPTE toolkit. The Working Group decided which of the 10 original recommendations should be adopted, which should be adopted with alterations, and which should either be rejected or require a new recommendation to be created. Finally, feedback was obtained from stakeholders impacted by the guideline and a process was established for the review and updating of the adapted guideline.

After completing the adaptation process, eight of the ten recommendations from the IOM Standard were adapted for Ontario by the Working Group. Five of the IOM recommendations (The Standard of Care, Healthcare Providers, Patient and Family Education, Workforce Competencies, Standardized Nomenclature, and Psychosocial Research) were adapted with minor changes. Two of the IOM recommendations (Quality Oversight and Promoting Uptake and Monitoring Progress) were merged and heavily modified to constitute Domain E of the framework. Two recommendations from the IOM Standard were not adapted for Ontario (Support for Dissemination and Uptake and Support from Payers) because they did not fit the context of Ontario.

The document was submitted to the Program in Evidence-based Care (PEBC) Report Approval Panel (RAP) for an initial review. Key issues raised by the RAP included:

  • The scope of the document should be reconsidered because the target audience of the IOM committee and that of the Psychosocial Oncology Working Group are not the same.
  • The document reads more like a framework than a guideline.
  • The document does not present actionable recommendations (e.g., the interventions are not profiled).
  • A suggestion was made to reframe the adapted recommendations into a framework, and for each one, based on the evidence provided by the IOM document and on the expert opinion of the Panel, create actionable recommendations or recommend the creation of new guidelines.

In response to the RAP review, the Psychosocial Oncology Working Group met several times in teleconference and reframed the nine adapted recommendations into an eight-domain framework (see Section 1 in the original guideline document). The evidence contained in the IOM standard was combined with the expert opinion of the members of the Working Group and was used to create actionable recommendations for psychosocial cancer care in Ontario. The document was significantly rewritten to incorporate the new framework organization and actionable recommendations.

To illustrate the development process from initial IOM recommendation to framework domain to actionable recommendation(s) that occurred during the initial drafting of the report and the revision in response to the RAP review, the opinion of the Working Group on the original IOM recommendations (with page numbers from the IOM document) is presented, with the adapted version of the recommendation transformed into a domain of the framework for psychosocial oncology in Ontario. The relative actionable recommendations and their justification, along with some example of strategies for implementation, are provided in the original guideline document.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Internal Review

Prior to the submission of this evidence-based series (EBS) draft report for external review, the report was reviewed by the Program in Evidence-based Care (PEBC) Report Approval Panel (RAP), which consists of two members, including an oncologist, with expertise in clinical and methodological issues, and by a panel of experts in the field of psychosocial oncology in Ontario.

External Review

The PEBC external review process is two-pronged and includes a targeted peer review that is intended to obtain direct feedback on the draft report from a small number of specified content experts and a professional consultation that is intended to facilitate dissemination of the final guidance report to Ontario practitioners. Following the review and discussion of Section 1: Framework and Summary Recommendations and Section 2: Development and Review (in the original guideline document) of this report and the review and approval of the report by the PEBC Report Approval Panel, the Psychosocial Oncology Working Group circulated Sections 1 and 2 to external review participants in Ontario for review and feedback.

Targeted Peer Review

During the guideline development process, seven targeted peer reviewers from Ontario considered to be clinical and/or methodological experts on the topic of psychosocial oncology were identified by the Working Group. Several weeks prior to completion of the draft report, the nominees were contacted by e-mail and asked to serve as reviewers. Six agreed, and the draft report and a questionnaire were sent via e-mail for their review. The questionnaire consisted of items evaluating the methods, results, and interpretive summary used to inform the draft recommendations. The questionnaire also asked whether the draft recommendations should be approved as a guideline. Written comments were invited. The questionnaire and draft document were sent out on July 14, 2010. Follow-up e-mail reminders were sent at two weeks and four weeks. The Psychosocial Oncology Working Group met and reviewed the responses to the questionnaire.

Professional Consultation

Feedback was obtained through a brief online survey of health care professionals who are the intended users of the guideline, namely clinical nurse specialists, clinical leaders, clinical coordinators in the supportive care and genetic counselling area, clinical consultants in palliative care, clinical managers, administrative managers, social workers, counsellors, registered dietitians, specialists in psychosocial oncology and palliative care, physiotherapists, spiritual care practitioners, psychologists and physicians in various specialties including oncologists and psychiatrists.

Participants were asked to rate the overall quality of the guideline and whether they would use and/or recommend it. Written comments were invited. Participants were contacted by e-mail and directed to the survey website where they were provided with access to the survey, the guideline recommendations (Section 1 in the original guideline document), and the evidentiary base (Section 2 in the original guideline document). The notification e-mail was sent on July 14, 2010. The consultation period ended on August 13, 2010. The Psychosocial Oncology Working Group reviewed the results of the survey.

Recommendations

Major Recommendations

Domain A. Raising Awareness: Understanding and Defining Psychosocial Care

Psychosocial care should be considered an integral and standardized part of cancer care for patients and their families at all stages of the illness trajectory. Strategies to promote awareness of the significance of psychosocial health care needs and uptake of psychosocial health services should be encouraged.

Recommendation

  1. That the definition put forward by the Canadian Association of Psychosocial Oncology (CAPO) be adopted to guide psychosocial oncology in Ontario:

    Psychosocial Oncology is a professional subspecialty [sic] in oncology. The domain of psychosocial oncology includes the formal study, understanding and treatment of the social, psychological, emotional, spiritual, quality of life and functional aspects of cancer as applied across the cancer trajectory from prevention through bereavement. It seeks to develop and integrate new knowledge and techniques of the psychosocial and biomedical sciences as it relates to cancer care (Canadian Association of Psychosocial Oncology, 2010).

Domain B. Standard of Care

Comprehensive cancer care should ensure the provision of appropriate psychosocial health services by:

  • Facilitating effective communication between patients, their families and care providers;
  • Identifying psychosocial health needs of patients and families;
  • Designing and implementing a plan that:
    • Links the patient/family with needed psychosocial health care services,
    • Coordinates biomedical and psychosocial health care,
    • Engages and supports patients/families in managing their illness and health; and
  • Systematically monitoring, evaluating, and re-adjusting plans.

Recommendations

Facilitating Effective Communication

  1. To improve the patient end of the patient-provider communication unit, organizations should provide and facilitate the use of tools to support communication and develop formal strategies to teach communication techniques to patients.

Identifying Psychosocial Health Needs

  1. All patients/families should be screened for psychosocial health care needs at their initial visit to a cancer treatment facility and at intervals throughout their cancer care trajectory, particularly with changes in disease status (e.g., remission, progression, recurrence).
  2. Screening should be performed with validated tools encompassing a comprehensive range of health-related psychosocial problems, including physical symptoms, emotional or spiritual distress, logistical or material needs, inadequate social supports, and behavioural risk factors.
  3. Results of screening should be shared with the patient and the health care team.
  4. Significant screening results should be followed up with an assessment by the most appropriate health care provider to confirm needs and develop a plan of care.

Designing and Implementing a Plan

  1. Health care providers should work with the patient and family to develop a plan of care that contains clear goals, aims at assisting in managing the illness and complex functional abilities (e.g., swallowing, communication, ambulation), and maintains the highest possible level of functioning and well-being.
  2. As part of the health care plan, patients need to be linked to the most appropriate health care provider, either within the organization or within the broader community.
  3. At the system level, structures and mechanisms should be put into place to ensure the coordination of biomedical and psychosocial care.
  4. Health care providers and patient advocacy organizations should provide patients and families with condition-specific information tailored to the individual patient’s learning needs and style.
  5. All health care providers and individuals working in community organizations should collaborate in the provision of emotional support for cancer patients and their families.
  6. Patients diagnosed with clinically significant depression and anxiety should be treated or referred for treatment with specific psychotherapies (e.g., cognitive-behavioural therapy, supportive psychotherapy, family/couples therapy) and/or pharmacotherapy, as indicated.
  7. Health care organizations should develop interprofessional collaborative care models for the delivery of comprehensive cancer care that ensures access to the full range of psychological, physical, social, emotional, spiritual, nutritional, informational, and practical services needed by cancer patients and their families to support illness self-management.
  8. Cancer programs and community-based not-for-profit cancer support organizations should assume responsibility for educating patients about the impact that health-risk behaviours can have on the disease and its treatment and provide information about community resources that can help patients with changing these behaviours.
  9. Cancer programs and community-based not-for-profit cancer support organizations should provide information and assistance to patients regarding medication and disability coverage, transportation, lodging during outpatient therapy, child care, wigs and prostheses, and material medical supplies.
  10. Cancer programs and community-based not-for-profit cancer support organizations should provide assistance in accessing services to address cancer-related disabilities, cognitive impairment, cultural and language barriers, and family and caregiver support.
  11. Health care providers should take into account the financial constraints of patients and support their access to appropriate services.

Systematically Monitoring, Evaluating, and Readjusting Plans

  1. Health care professionals should systematically follow up on the uptake of services by patients, as well as any problems encountered, and patient satisfaction with care.

Domain C. Health Care Providers

All cancer care providers, including oncologists, palliative care physicians, family physicians, psychiatrists, psychologists, social workers, nurses, dietitians, occupational therapists, physiotherapists, speech language pathologists, spiritual care practitioners, health care administrators, volunteers, community organizations, and other health care providers, have a responsibility to ensure that cancer patients and their families receive the psychosocial standard of care.

Recommendations

  1. All cancer care providers should participate in education and training programs to increase their awareness of the significance of psychosocial care and enhance their skills in the assessment and management of psychosocial issues.
  2. Communication and patient education are expectations of clinical care. All health care providers should seek training in these areas.
  3. Health care providers should maintain a directory of resources available to patients and their families at no cost.

Domain D. Patient and Family Education

Cancer patients and their families should be educated to expect, and request when necessary, cancer care that meets psychosocial health care needs.

Recommendation

  1. Cancer programs should establish comprehensive cancer patient education programs.

Domain E. Quality Oversight and Monitoring Progress

Oversight mechanisms should be created that can be used to measure and report on the quality of psychosocial health care. These findings could be used to inform an evaluation of the impact of this report.

Recommendation

  1. Indicators to measure the effectiveness of psychosocial care and services should be identified and included in regional and provincial reporting, including, but not limited to, understanding the patient's experience with care.

Domain F. Workforce Competencies

Professional competencies in the delivery of psychosocial health care should meet the requirements of educational institutions and accrediting organizations, licensing bodies, and professional societies.

Educational bodies should examine their standards and licensing and certification criteria with an eye to identifying competencies in delivering psychosocial health care and developing them as fully as possible in accordance with a model that integrates biomedical and psychosocial care.

Recommendations

  1. Workforce planning for cancer services should include planning for all psychosocial specialists (i.e., social workers, psychologists, psychiatrists, nurses, spiritual care practitioners, dietitians, and rehabilitation professionals such as occupational therapists, physiotherapists, and speech language pathologists) to meet the growing needs and demands for care.
  2. Volunteers and patient education and information specialists have unique roles to inform, support, and help navigate cancer patients through their experience. Human health resource planning should take into consideration the need for such providers as part of the psychosocial service planning.
  3. Cancer programs should support additional education for health care professionals, given they may not have specialized credentials in psychosocial oncology. Relevant courses such as the Inter-professional Psychosocial Oncology Distance Education Program (IPODE, http://www.ipode.ca/ External Web Site Policy) should be made available to all health care professionals who care for cancer patients and their families.

Domain G. Standardized Nomenclature

There is a need to develop a standardized, trans-disciplinary taxonomy and nomenclature for psychosocial health services.

Recommendation

  1. The Canadian Association of Psychosocial Oncology (CAPO), the Canadian Partnership Against Cancer (CPAC), and Cancer Care Ontario (CCO) should collaborate with provincial, national, and international bodies to develop a standardized, trans-disciplinary taxonomy and nomenclature for psychosocial health services.

    This initiative should aim to incorporate this taxonomy and nomenclature into an organization of practices and education, as well as into databases such as the National Library of Medicine Medical Subject Headings (MeSH), PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Excerpta Medica Database (Embase).

Domain H. Psychosocial Research

Organizations sponsoring research in oncology care should include the following areas among their funding priorities:

  • At the system level, further development of reliable, valid, and efficient tools and strategies for use by clinical practices to ensure that all patients with cancer receive appropriate psychosocial care as set forth in the Standard of Care. These tools and strategies should include:
    • Approaches for improving patient-provider communication and providing decision support to cancer patients
    • Screening instruments that can be used to identify individuals with psychosocial health problems
    • Needs assessment instruments to assist in planning psychosocial services
    • Illness and wellness management interventions
    • Approaches for effectively linking patients with services and coordinating care, and for the uptake of psychosocial health services
  • At the provider level, the identification of more effective psychosocial services to treat mental health problems and to assist patients in adopting and maintaining healthy behaviours such as smoking cessation, exercise, and dietary changes. This effort should include:
    • Identifying populations for whom specific psychosocial services are most effective
    • Increasing the focus on understudied populations such as men and children, and understudied cancer types across the cancer trajectory and in patients experiencing different types and levels of distress
    • Developing standard outcome measures for assessing the effectiveness of these services

Research on the use of these tools, strategies, and services should also focus on barriers to patient referral, and how best to ensure the delivery of appropriate psychosocial services to vulnerable populations such as those with low literacy, older adults, the socially isolated, those living in remote areas, and those who are members of cultural minorities.

Recommendations

  1. Future research on the effectiveness of psychosocial health services should consider variables that moderate treatment effects, such as a priori consideration of the nature of the samples (i.e., levels of distress, natural course of symptoms, availability of social supports, temperamental traits, demographics), as well as theory-guided examinations of mechanisms for the obtained effects.
  2. The development of more effective treatments for mental health problems in cancer particularly through randomized controlled trials (RCTs) testing collaborative care and multicomponent interventions and comparing the effectiveness of non-pharmacologic and pharmacologic treatments alone and combined.
  3. An increased focus on the effects of receipt of psychosocial health services on physiological (i.e., endocrine and immunological functioning) and clinical outcomes, including nutritional and functional status.
  4. Provincial and federal cancer research funding agencies should increase their support for psychosocial research. This can be accomplished either through dedicated funding priority calls for psychosocial care or by increasing funding allocation for psychosocial research in grant competitions.
Clinical Algorithm(s)

An algorithm is provided in the original guideline document for the psychosocial oncology framework outlined in the Institute of Medicine (IOM) document.

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is not specifically stated for each recommendation.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate psychosocial health care for cancer patients and their families
  • Patients' active participation in their own care and lifestyle changes can significantly affect the severity of the disease and its impact on quality of life.
Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • Care has been taken in the preparation of the information contained in this report. Nonetheless, any person seeking to apply or consult the report is expected to use independent medical judgment in the context of individual clinical circumstances or seek out the supervision of a qualified clinician. Cancer Care Ontario makes no representation or guarantees of any kind whatsoever regarding the report content or use or application and disclaims any responsibility for its application or use in any way.
  • Since this is not a de novo guideline but rather an adaptation of the Institute of Medicine (IOM) standard, the content of this document reflects the original from which it was drawn. For this reason, some important aspects of psychosocial care (e.g., highlighting in the framework aspects of the cancer care continuum, expanding the research section, prioritizing psychosocial needs) that were not included in the original IOM document have not been included here. In some cases, when actionable recommendations were made for which the IOM document did not contain sufficient supportive evidence for intended users in Ontario, the existing evidence was integrated, with the expertise of the Group, and recommendations for the development of future guidelines were constructed as needed.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Clinical Algorithm
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Turnbull G, Baldassarre F, Brown P, Hatton-Bauer J, Li M, Lebel S, Durkin L, Green E, Psychosocial Oncology Expert Panel. Psychosocial health care for cancer patients and their families. Toronto (ON): Cancer Care Ontario (CCO); 2010 Oct 12. 65 p. (Evidence-based series; no. 19-3).  [134 references]
Adaptation

This guideline was adapted from the following source:

  • Institute of Medicine of the National Academies. Cancer care for the whole patient: meeting psychosocial health needs. Adler NE, Page AEK, editors. Washington (DC): The National Academies Press; 2008.
Date Released
2010 Oct 12
Guideline Developer(s)
Program in Evidence-based Care - State/Local Government Agency [Non-U.S.]
Guideline Developer Comment

The Program in Evidence-based Care (PEBC) is a Province of Ontario initiative sponsored by Cancer Care Ontario and the Ontario Ministry of Health and Long-Term Care.

Source(s) of Funding

Cancer Care Ontario
Ontario Ministry of Health and Long-Term Care

Guideline Committee

Psychosocial Oncology Working Group

Composition of Group That Authored the Guideline

Members: Ms. Gale Turnbull (Manager), Manager, Supportive Care & Education, Regional Lead for Palliative Care, London Regional Cancer Program; Ms. Fulvia Baldassarre (Registered Nurse), Research Coordinator, Program in Evidence-based Care, McMaster University; Ms. Pat Brown (Manager), Manager, Patient and Family Support Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre; Ms. Jane Hatton-Bauer (Registered Dietitian/Manager), Regional Coordinator of Supportive Care, Grand River Regional Cancer Center; Dr. Madeline Li (Psychiatrist), Psychosocial Oncology and Palliative Care, University Health Network, Princess Margaret Hospital; Dr. Sophie Lebel (Psychologist), Assistant Professor/Professeure adjointe, University of Ottawa, School of Psychology/École de Psychologie; Ms. Lisa Durkin (Speech Language Pathologist), University Health Network, Princess Margaret Hospital

Financial Disclosures/Conflicts of Interest

The authors of this report declared that there was no conflict of interest. However, it may well be that the standard definition of conflict does not readily apply in this context. While the individual authors may not have any direct interest in the establishment of psychosocial health services in Ontario, it is acknowledged and duly declared that funding derived from the implementation of psychosocial health services or the possible benefit to centres that provide training for psychosocial health services could be construed as a possible conflict of interest.

Guideline Status

This is the current release of the guideline.

The EVIDENCE-BASED SERIES report, initially the full original Guideline, over time will expand to contain new information emerging from their reviewing and updating activities.

Please visit the Cancer Care Ontario Web site External Web Site Policy for details on any new evidence that has emerged and implications to the guidelines.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Cancer Care Ontario Web site External Web Site Policy.

Availability of Companion Documents

The following is available:

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on February 2, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please refer to the Copyright and Disclaimer Statements External Web Site Policy posted at the Program in Evidence-based Care section of the Cancer Care Ontario Web site.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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