David Kerr, MD, DSc

DISCLOSURES

June 25, 2026

This transcript has been edited for clarity.

Hello. I’m David Kerr, professor of cancer medicine at University of Oxford. Today, I’d like to talk a little about an excellent publication that’s popped up in Annals of Oncology, my old journal. This is a set of guidelines produced by the European Society for Medical Oncology (ESMO) guidelines group as to how to best, as they would recommend, manage metastatic colorectal cancer.

It’s an excellent document with a fantastic cast of contributory authors, bringing us up to date with the latest in terms of multidisciplinary management of advanced disease. It builds on personalized medicine, how we use biomarkers to best select patients, how we judge treatment according to the tempo of disease, and so on. It’s an excellent document.

I wanted to use it as a segue to discuss more widely how we use guidelines. I’m one of the architects of the British National Cancer Plan. I distilled it down to four very simple elements. This is, goodness, probably thirty years ago when we came together with Mike Richards to produce the plan. I thought that it should be site specialization, in those days, particularly surgical-site specialization guidelines, to help provide a framework as to how we would best treat cancer patients, working in multidisciplinary teams. Every single new cancer patient in the United Kingdom has their case discussed by a full multidisciplinary team. [This would be] a remarkable step forward, perhaps using, naively, some IT to glue it all together to provide a sort of interconnectedness, if you like.

Picking up on the guidelines, this to me felt as if leveling up. It wasn’t about wanting to constrain treatment, but about trying to avoid bad treatment or no treatment, to provide standards and to provide guidance. There was good evidence, particularly in the hematologic community, that when the Medical Research Council (MRC) was running some very large, randomized trials in leukemia centers which adhered to the MRC protocols, the patients did better than those who didn’t.

This was not really because there was any magical advance in treatment, but just because the guidelines produced a very safe, formulaic way of delivering treatment. It built in dose reductions and those delays. It gave advice as to how to manage side effects and so on. That protocolized delivery of cancer care carried over into better care. That was the background to it.

We now have a proliferation of international guidelines. We have ESMO, we have the American Society of Clinical Oncology, we have the National Comprehensive Cancer Network (NCCN). These are the three most widely used groups of guidelines in the world. We did a survey of this some years ago, with NCCN probably coming out on top. They offer different things, but they’re all a pretty good place to go. They’re increasingly accessible, available in apps and mobile phones and so on. And being able to guide individuals through the increasingly labyrinthine nexus of choice for managing cancer, I think, is a really, really good thing.

Where it gets complicated, though, is we need to ask ourselves, does it squash individualization? I still think I’m a moderately thoughtful cancer doctor. From time to time, I would like to do things in which I think it’s rational to combine drugs A and B with drug C. Now, they may not be in the guidelines and therefore not in the formulary. With modern electronic prescribing, it proves almost impossible, even for a very experienced senior cancer doctor like myself, to think a little laterally — to think it’s worth a chance trying drugs A and B plus C or whatever the combination might be — because the guidelines don’t mandate it, it’s not picked up on our prescribing formulary, and therefore it becomes a battle to be able to do something that’s innovative.

Now, can we be innovative if we’re talking about a single patient and N of 1? Although I’m a great promulgator, a fan, a supporter, and somebody who helped institutionalize guidelines nationally and internationally, I think they’ve maybe gone a wee bit too far in terms of hemming in our individual creativity, I think, is probably the right word, but our laterality of thought.

I’d be interested to see what you think. Are guidelines a good thing? Of course, yes, they are, because they level up the quality of treatment unquestionably. Should we be allowed some freedom and laterality of thought to go off-piste, to use a skiing analogy, from time to time if individual patients demand and if the treating doctor comes up with a good idea? It seems reasonable to me, but I’d be very interested to see what you thought.

For the time being, as always, thanks for listening. Medscapers, over and out. Thank you.

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Cite this: Are Cancer Guidelines Hemming In Creativity? - Medscape - June 25, 2026.