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Quality and consistency of clinical practice guideline recommendations for PET/CT and PET: a systematic appraisal

  • Nuclear Medicine
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objectives

To systematically appraise the methodologies used for guidelines for positron emission tomography (PET) imaging and to compare the consistency of these recommendations.

Methods

We searched PubMed, EMBASE, four guideline databases, and Google Scholar to identify evidence-based clinical practice guidelines pertaining to the use of PET, PET/computed tomography (CT), or PET/magnetic resonance in routine practice. We assessed the quality of each guideline using the Appraisal of Guidelines for Research and Evaluation II instrument and compared recommendations regarding indications for 18F-fluorodeoxyglucose (FDG) PET/CT.

Results

Thirty-five guidelines for PET imaging, published between 2008 and 2021, were included. These guidelines performed well in the domains of scope and purpose (median 80.6%, inter-quartile range [IQR] 77.8–83.3%) and clarity of presentation (median 75%, IQR 69.4–83.3%), but poorly in applicability (median 27.1%, IQR 22.9–37.5%). Recommendations for 48 indications in 13 cancers were compared. Considerable inconsistencies in the direction of whether to support the use of FDG PET/CT were observed in 10 (20.1%) indications pertaining to 8 cancer types: head and neck cancer (treatment response assessment), colorectal cancer (staging in patients with stages I–III disease), esophageal cancer (staging), breast cancer (restaging and treatment response assessment), cervical cancer (staging in patients with stage < IB2 disease and treatment response assessment), ovarian cancer (restaging), pancreatic cancer (diagnosis), and sarcoma (treatment response assessment).

Conclusions

Current guidelines for PET imaging vary in methodological quality and provided considerably inconsistent recommendations. Efforts are needed to improve adherence to guideline development methodologies, to synthesis high-quality evidence, and to adopt standard terminologies.

Protocol registration number

PROSPERO CRD42020184965.

Clinical relevance statement

Guidelines for PET imaging provide considerably inconsistent recommendations and vary in methodological quality. It is suggested that clinicians be critical of these recommendations when applying them in practice, that guideline developers adopt more rigorous development methodologies, and that researchers prioritize research gaps identified by current guidelines.

Key Points

• PET guidelines vary in methodological quality and provided inconsistent recommendations. Efforts are needed to improve methodologies, synthesize high-quality evidence, and standardize terminologies.

• Among six domains of methodological quality assessed by the AGREE II tool, guidelines for PET imaging performed well in scope and purpose (median 80.6%, inter-quartile range 77.8–83.3%) and clarity of presentation (75%, 69.4–83.3%), but poorly in applicability (27.1%, 22.9–37.5%).

• Among the 48 recommendations (for 13 cancer types) compared, conflicts in the direction of whether to support FDG PET/CT use were observed in 10 (20.1%), for 8 cancer types (i.e., head and neck, colorectal, esophageal, breast, cervical, ovarian, pancreatic, and sarcoma).

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Abbreviations

AGREE:

Appraisal of Guidelines for Research and Evaluation

ASCO:

American Society of Clinical Oncology

AUC:

Appropriate use criteria

BMA:

Brazilian Medical Association

CCO:

Cancer Care Ontario

FDG:

18F-Fluorodeoxyglucose

MOPH:

Ministry of Public Health

PET/CT:

Positron emission tomography/computed tomography

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta Analyses

RIGHT:

Reporting Items for practice Guidelines in HealThcare

SFMN:

French Society of Nuclear Medicine

SNMMI:

Society of Nuclear Medicine and Molecular Imaging

SPNs:

Solidary pulmonary nodules

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Acknowledgements

This study was supported by the National Natural Science Foundation of China (grant no. 7210040335 and 81971653), and the 1.3.5 Project for Disciplines of Excellence, West China Hospital, Sichuan University (grant no. ZYYC08003 and ZYJC21063). The funding sources had no role in the design of this study and did not have any role during its execution, analyses, interpretation of the data, or decision to submit results.

Funding

This study was supported by the National Natural Science Foundation of China (grant no. 7210040335 and 81971653), and the 1.3.5 Project for Disciplines of Excellence, West China Hospital, Sichuan University (grant no. ZYYC08003 and ZYJC21063). The funding sources had no role in the design of this study and did not have any role during its execution, analyses, interpretation of the data, or decision to submit results.

Author information

Authors and Affiliations

  1. Department of Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China

    Qianrui Li, Wenxiu Hou, Minggang Su, Futao Cui & Rong Tian

  2. Chinese Evidence-Based Medicine Center, Cochrane China Center, and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China

    Qianrui Li, Ling Li, Yan Ren, Jiayue Xu, Kang Zou & Xin Sun

  3. National Medical Products Administration Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, Sichuan, China

    Qianrui Li, Ling Li, Yan Ren, Jiayue Xu, Kang Zou & Xin Sun

  4. Sichuan Center of Technology Innovation for Real World Data, Chengdu, China

    Qianrui Li, Ling Li, Yan Ren, Jiayue Xu, Kang Zou & Xin Sun

  5. Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China

    Mei Wu & Bin Ma

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  1. Qianrui Li
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Corresponding authors

Correspondence to Rong Tian or Xin Sun.

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Guarantor

The scientific guarantor of this publication is Professor Xin Sun, from Chinese Evidence-based Medicine Centre, West China Hospital, Sichuan University.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

Some of the authors (Dr. Yan Ren and Dr. Jiayue Xu, both received PhD in statistics) has significant statistical expertise.

Informed consent

This was a cross-sectional survey of published literatures that did not involve human subjects, and hence informed consent was not applicable.

Ethical approval

This was a cross-sectional survey of published literatures that did not involve human subjects, and hence was exempt from institutional review board approval.

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  • cross-sectional study

  • literature survey

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Li, Q., Hou, W., Wu, M. et al. Quality and consistency of clinical practice guideline recommendations for PET/CT and PET: a systematic appraisal. Eur Radiol 33, 7879–7889 (2023). https://doi.org/10.1007/s00330-023-09786-8

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  • DOI: https://doi.org/10.1007/s00330-023-09786-8

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