Which is more important for doctors in a middle-income country, a national guideline or the medical literature? An adherence survey of trastuzumab use for breast cancer in Iran

• The Iranian guideline recommends a 9-week regimen for trastuzumab, instead of a 52-week regimen currently recommended in many other countries.
• Iranian doctors mostly prescribe a 52-week regimen and therefore appear to rely more on the medical literature than on the national guideline.
• The resource-sensitive guidelines are affected by the poor degree of clinician adherence in middle income countries.
• Clinician adherence could be enhanced by promoting mutual awareness between doctors and policymakers regarding the socioeconomic impacts of their decisions.

IntroductionMost national standard therapeutic guidelines in the world recommend a 52-week trastuzumab regimen for breast cancer treatment. In contrast, the national guideline published by the Iranian Ministry of Health recommends a nine-week regimen. Since guidelines are not necessarily followed in daily practice, we assessed the extent to which current routine practice in Iran as a middle-income country matches the recommendations found in these guidelines.Methods128 Iranian oncologists were asked to complete an online anonymous questionnaire. Concurrently, a 3-year retrospective claims database analysis was conducted using data from the Social Security Organization, a health insurer which covers approximately 50% of the Iranian population, to enable comparisons with the questionnaire results.ResultsWith a 41% (52/128) response rate, doctors reported a relatively high absolute adherence (86%) to the guideline for HER2 receptor testing but a low rate of absolute adherence (6%) to the guideline for duration of trastuzumab treatment. Doctors indicated that the planned duration was 9 weeks in only 33% of patients; in most cases, the plan was 52-week treatment. Patients with a 9-week treatment plan received trastuzumab for 8.6 weeks on average while patients with 52-week plans received treatment for 29.2 weeks. The general trends found in the survey were confirmed in the claims database analysis of 1295 HER2-positive patients.ConclusionsResource-sensitive guidelines may be beneficial in middle-income countries where limited budgets cannot accommodate all innovative technologies. However, Iranian physicians appear to rely more on the medical literature than on national guidelines regarding trastuzumab use. Policymakers, doctors and other stakeholders need to reach some consensus about the optimal way to treat patients. A national guideline needs to be accompanied with country-specific economic evaluations.