Guideline for managing breast lumps
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* John F. Gately

The editors have stated that they would like to receive and publish comments from readers of the Journal. I would therefore like to comment on the letter concerning a guideline for the management of breast lumps by Mahoney and colleagues (*Can J Surg* 1998;41[6]:476–7).

To issue algorithms or guidelines without the supporting rationale or evidence is not a valid exercise. To understand what is involved in developing guidelines, I would respectfully refer the editors to the methodology of the practice guidelines development cycle.1 This process is used by the Ontario Cancer Treatment Practice Guidelines Initiative. The purpose of the Initiative is to improve the outcomes for cancer patients, to help practitioners apply the best available research evidence to clinical decisions and to promote responsible use of health care resources. The development of guidelines is clearly a time-consuming iterative process. One might infer, erroneously or not, that a group of interested individuals in the University of Toronto has arrived at a “consensus” over a cup of coffee.

With reference to Mahoney’s algorithm on page 477, what is the evidence underpinning the recommendation that a 45-year-old woman with no clinical evidence of breast cancer and no risk factors be subjected to biannual mammography?

The risk of breast cancer increases with age. The Ontario Breast Screening Program provides screening only for women 50 years of age or older. Even for this group of women, the evidence of benefit is sparse, and some would argue that the risk of harm outweighs any putative benefit.

If the editors of the Journal are looking forward to developing a series of credible guidelines for managing common surgical problems, they must stipulate the methodology to be employed. Like it or not, we are living in an era of evidence-based surgery.

## Reference

1.  Browman GP, Levine MN, Mohide EA, Hayward RSA, Pritchard KI, Gafni A, et al. The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol 1995 ;13(2):502–12.
    
    [Abstract/FREE Full Text](http://canjsurg.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiamNvIjtzOjU6InJlc2lkIjtzOjg6IjEzLzIvNTAyIjtzOjQ6ImF0b20iO3M6MjA6Ii9janMvNDIvMi8xNTAuMS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)