Annals of Oncology 9: 377 383, 1998. 1998 Kluwer Academic Publishers. Primed in the Netherlands.

Review on evidence-based cancer medicine
Searching the medical literature for the best evidence to solve clinical questions
D. L. Hunt, R. B. Haynes & G. P. Browman
Health Information Research Unit. Department of Clinical Epidemiology and Biostatistics, Me Master University Faculty of Health Sciences, Hamilton, Ontario, Canada

Key words: continuing education, evidence-based medicine, information retrieval, information technology, Internet, keeping up-to-date
Downloaded from annonc.oxfordjournals.org by guest on February 6, 2011

Introduction Questions about the best care for our patients' problems arise frequently in clinical practice. The pace of development of new evidence from research is too quick for standard textbooks to be of dependable help. Most often, these questions relate to the best means of confirming a diagnosis or the optimal therapeutic approach for a given condition. At other times, risk factors, screening, or prognosis may be the principal concerns. Or the questions may relate to the co-morbid conditions of the patient, such as the interactions of their medications for heart disease or diabetes with the treatments that they might receive for their cancer. When these questions arise, it is unlikely that they will be answered accurately (or at all) unless we are able to find the answers quickly and accurately. As the current best evidence on a given topic changes at unpredictable times, even the most experienced clinician cannot assume that she knows the answer without looking. Fortunately, the advent of better research, better information resources, and better information technology makes it possible and worthwhile for all clinicians to respond to these challenges by learning some basic literature search skills and acquiring access to key evidence resources in the hospital and clinic or at home. In this article, we will describe and illustrate some of the skills and resources for answering questions of relevance to the care of patients with cancer.

Clinical scenarios Consider the following situations. You have just finished seeing a 62-year-old man who was recently diagnosed with locally advanced squamous cell carcinoma of the oral cavity. The patient is a smoker and drinks alcohol moderately; he has no other significant medical conditions and the tumour appears to be amenable to surgery. A visiting medical student is doing an elective with

you. She recalls from a recent lecture that chemotherapy can be effective at improving survival for patients with squamous cell head and neck cancers and asks you about offering this patient a short course of chemotherapy before surgery. You are quite certain that neoadjuvant chemotherapy is not beneficial for patients with locally advanced oral cancer but as you are about to explain this, you realize that you do not know whether this has been properly evaluated. You quickly turn the tables on the student and suggest that she provide a reference from the literature for your next meeting. To avoid being upstaged (again!), you set off on your own search. Before you have had a chance to begin finding an answer, a colleague who coordinates the breast cancer screening program at your hospital approaches you with another question. She is concerned about one of her recent cases. After having a mammogram that was interpreted as being suspicious for malignancy, the woman went on to have a breast biopsy. This showed no evidence of cancer. The patient was naturally elated with the good news. On reviewing her mammogram with a second radiologist, it was suggested that the biopsy was not needed in the first place: the mammogram was negative. Your colleague wonders whether any changes could be made to the mammography screening program to decrease the number of unnecessary breast biopsies, without missing additional cases of breast cancer. She is considering proposing a policy at the next medical staff meeting that would require all mammograms to be read by two radiologists before being reported, but is interested in your thoughts. How would you go about trying to address these questions? The first step is to carefully define the questions. The second step is to retrieve the best current evidence that pertains to the question, a task that includes choosing an appropriate evidence resource; developing and executing an effective search strategy; critically appraising the results; and refining the search

MEDLINE and CANCERLIT both contain an enormous number of citations. This is known as the Medical Subject Heading (MeSH) vocabulary. Some vendors. CDP Technologies. MEDLINE indexes citations for content and methodology using a set of over 14.gov/PubMed/ clinical. for anyone who has access to the Internet. what are the effects of duplicate independent interpretation on the diagnostic accuracy and costs of screening? Downloaded from annonc. describing research from 'bench to bedside'. CANCERLIT includes almost all of the cancer-related citations in MEDLINE. an article is assigned a number of MeSH terms. Returning to the therapeutic question at hand. and the approach to using CANCERLIT is identical. through PubMed (http:// www.oxfordjournals.gov). such as MEDLARS. a basic understanding of how articles are indexed in MEDLINE is highly desirable for clinical users. what is the effect of neoadjuvant chemotherapy on survival? For women undergoing screening mammography. the questions could be: For patients with locally advanced and surgically resectable squamous cell cancer of the head and neck. During the indexing process. Some MEDLINE systems do this by referring to these topics as major subject headings. Nevertheless. or the Canada Institute for Scientific and Technical Information (1-800-668-1222). and HealthGate provide both online access and access over the Internet. Librarians have a wealth of experience in using these services and are valuable consultants for clinicians.000 specific terms and over 18. Finally. or SilverPlatter. Many hospital and academic libraries have CD-ROM based systems such as OVID. book citations and theses.nih. clinically relevant studies requires thought and preparation and even then may miss important studies (low sensitivity) while retrieving many studies that are not relevant to the searcher's purpose (low precision).org by guest on February 6. This entails identifying a question that is important to the patient's well-being.uk/cancernet/400006. Ovid also provides access to a growing number of full text journal articles. A more complete listing of information about CANCERLIT distributors is available at http://www. the diagnostic test or treatment or other clinical issue that you are addressing. Internet Grateful Med also includes several additional databases such as AIDSLINE and SDILine (which permits storing your own search strategies for periodic updates on specific topics). Ovid.html. Clinicians in the United Kingdom. Over 7. Knight-Ridder Information. DIALOG. (For practical purposes. PubMed also provides links to a small but growing number of fulltext articles via the internet home pages of journals. which includes citations and their abstracts before they have been indexed by the US National Library of Medicine.ncbi. you are interested in finding studies that have evaluated the role of neoadjuvant chemotherapy for patients with squamous cell head and neck cancer. MEDLINE access became available free of charge. and the outcome that you are interested in. Asking whether post-menopausal women with Stage 1 breast cancer that has been treated with lumpectomy and local radiation therapy have prolonged survival if treated with tamoxifen is an example of a focussed question that is more amenable to answering.ncbi. . Aries.gov/PubMed) and Internet Grateful Med (http://igm. The majority of these vendors also provide MEDLINE access. and Canada can call the Health Care Information Service (0171 412 7477).000. Searching for high quality.nih.) To be answerable. For the two scenarios above. the findings must be applied in a way that fits the clinical circumstances of the patient and respects their wishes.graylab. the National Library of Medicine (1-800-272-4787). PubMed provides direct access to special search strategies that filter the literature for studies that are most likely to be applicable to clinical practice (http://www. United States. Both services provide access to all MEDLINE citations as well as the PreMEDLINE database.. This multipurpose database of medical literature citations and abstracts is produced by the US National Library of Medicine (NLM). is interesting to you. Online access using a modem or internet line is available through a number of vendors.nih. Topics that are the major focus of the article are specially coded to indicate this.378 strategy or moving on to a different database if necessary. Accessing CANCERLIT is generally quite easy. For example. Luckily.nlm.html).000 synonyms and other terms. however. while other sys- Defining the question The first step for any evidence search is to formulate a 'well-built clinical question' [1]. asking whether chemotherapy helps patients with breast cancer is a very broad question that would be difficult to answer. to inquire about regional medical libraries and programs that have been established to provide MEDLINE training. Recently.ac. Inc. and that you are likely to encounter on a regular basis in your practice. the question must be specified clearly so that it includes a specific patient group. and HealthGate. including MEDLARS. CANCERLIT is a special subset of MEDLINE prepared by the National Cancer Institute's International Cancer Information Center. but also has abstracts from meeting proceedings. some libraries offer training courses in MEDLJNE searching.nlm. it is more efficient and usually better for your patient if you seek consultants for questions that you seldom address in your practice. 2011 Finding best evidence MEDLINE and CANCER LIT MEDLINE is one of the most readily available resources for locating important studies.000 clinical and pre-clinical studies are indexed in MEDLINE. CD-Plus. This comprehensive approach has its price.nlm. respectively.

For example. and systematic reviews. One approach could be to use the MeSH term 'mortality'. you could do a second search using the MeSH term 'chemotherapy. diagnosis. naturally. however. Its evidence-based conclusion is that chemotherapy significantly increases treatment toxicity and only improves survival when used concurrently with local definitive therapy. In this case. To find the article on apples and oranges. MEDLINE allows citations from different searches to be combined in various ways. will be to scan the abstract and then jump to the conclusions. IGM provides a point-and-click feature for 'publication types'. IGM automatically explodes this term to include all head and neck neoplasms. Combining this term with the first two search terms above retrieves eight articles. you should combine the search results using the term 'AND'. Textword searching involves asking MEDLINE or CANCERLIT to search all of the titles and abstracts in its database for any occurrence of a term. This retrieves over 16. too many to read through in a limited amount of time! As you are most interested in finding information about how neoadjuvant chemotherapy affects survival in patients with head and neck malignancies. if you want to pool all of the citations that appear in either of the sets of retrieved articles. you can instruct MEDLINE to combine the sets using the term 'AND'. Different terms are helpful for identifying studies pertaining to questions of therapy. Asking MEDLINE to 'explode' a term indicates that you want all articles that include that term to be retrieved. you are only interested in articles that deal with both chemotherapy and head and neck cancer. that is. as is the case for several related terms for review articles. a search using the term 'explode fruits' would retrieve all citations that discussed fruits in general. as well as articles on apples and oranges (and pomegranates and so on). before it has its own MeSH term. you find that the paper is a meta-analysis of previous studies that have evaluated the role of chemotherapy in the management of squamous cell carcinoma of the head and neck region. but not all. intended to limit the number of studies retrieved to those that are most likely to be methodologically sound. it is the only way to search for citations in the PreMEDLINE database because these references have not been assigned MeSH terms. and then to proceed to evaluate the findings if the study methodology is acceptable. a textword search could be used. Three of these reports include meta-analyses of studies of adjuvant chemotherapy for head and neck cancer. An important feature of textword searching is the ability to search for all occurrences of a certain series of letters. it is important to begin by at least quickly assessing how a study was conducted. It is important to note that when the appropriate subject heading for an article is being chosen.oxfordjournals. Doing a search using the MeSH term 'fruits' would not retrieve the article because only articles that deal with fruits in general would be indexed using the term 'fruits'. As an alternative to the textword search. adjuvant'. diagnostic tests. you could begin by using the MeSH term 'head and neck neoplasms'. This approach is especially useful when searching for information about a relatively new topic. To limit the list of citations to these articles. To continue with the food theme. However. such as a new drug or procedure.379 terns place an asterisk (*) in front of the medical subject heading. Several publications [3-9] have presented systematic approaches to assessing articles about many different types of studies. can contribute to drawing inappropriate conclusions from studies. it would be indexed using these terms. review studies that summarize the evidence across relevant trials. to be evoked when desired. This second search retrieves over 3000 citations. You now have a manageable list of citations to review. narrowing your search to include only articles that deal with mortality would be appropriate. To whittle this down. This can be accomplished by adding methodological terms into search strategies [10. the most specific index terms available are used. Searching using the textwords 'mortality or survival' and then combining the results with the previous search using 'AND' produces a list of about 27 citations in the 1994-1997 MEDLINE database. you can combine the sets using the term 'OR'. at times you will find it very helpful to combine a content search. regardless of what letters come afterwards. the meta-analysis publication type is not consistently applied in MEDLINE as yet. Retrieving the first relevant article that your search has identified [2]. you will want to combine them. with a methodological quality search. the MeSH term 'apple' or 'orange' would need to be used. While in this case it is not crucial to limit the set yet further.org by guest on February 6. 2011 . including reports that use meta-analysis. Also. For the head and neck cancer search. Unfortunately. Rather. but not when used as induction treatment. Using the most sensitive strategy in Table 1 for identi- Downloaded from annonc. The temptation.'neoplasms' and 'neoplastic'. but there are still over 400. such as the one just completed. or a special feature of MEDLINE called 'exploding' could be used. along with all articles that have been indexed using more specific topics. PubMed has these methodological filters built in so that you do not need to keep a copy of them in your lab coat. prognosis studies. prognosis. and etiology (see Table 2). For example. Using Internet Grateful Med (IGM) for your search. if only articles that appear in both sets are desired. For example. Alternatively. CANCERLITand MEDLINE systems to denote this concept) would retrieve citations with a variety of terms including 'neoplasm'. This approach. On the other hand. a textword search using the term 'neoplas:' (the symbols'for " " a r e used by many.000 citations in the 1994 to September 1997 version of MEDLINE. if an article is about apples and oranges (and assuming that the MeSH vocabulary actually included such edible products). Most MEDLINE systems will allow users to store such filters. This produces a much smaller list of articles. A simplified approach to critical appraisal appears in Table 1. including therapeutic interventions. 11]. the article 'passes muster' as a systematic review. you could limit the search to meta-analyses.

so that some valuable information may be in EMBASE that is not included in MEDLINE. AND ratio:. OR specificity. " Based on references 10 and 11.tw.tw. more than 200. OR case. one is about nasopharyngeal cancer. 2011 Etiology or cause Combination of terms with best specificity: Combination of terms with best sensitivity: Cohort studies OR case-control studies Explode cohort studies OR explode risk OR odds. MEDLINE indexing for practice guidelines is improving but is not yet perfect. EMBASE is considerably more expensive to use than MEDLINE (the production of which is supported by US taxpayers and subsidised by foreign end-users).tw. OR predict:. This leaves but one potentially relevant study. applied to all participants Explicit criteria for rating relevance and merit Hollow-up of at least 80% Blinded assessment of test and diagnostic standard Follow-up of at least 80% Inclusion of all relevant studies " Based on references 3-9. One of the two papers on head and neck cancer treatment is a non-randomized study assessing the role of chemotherapy and radiotherapy in organ preservation. but a search for 'head and neck neoplasms' did not yield any citations for locally advanced head and neck cancer in this instance.tw. OR diagnostic use (as a subheading of the subject) Prognosis Combination of terms with best specificity: Combination of terms with best sensitivity: Prognosis OR survival analysis Incidence OR explode mortality OR follow-up studies OR prognos:. EMBASE and MEDLINE overlap in coverage but are not coincident. and some ingenuity and luck in searching are required. AND risk. Clinical trials are not as consistently indexed in EMBASE.tw.tw. blinding of observers of exposure to outcome Follow-up of at least 80% Reviews Comprehensive search for relevant articles Outcome measure of known or probable clinical importance Objective or reproducible diagnostic standard. the outcome of interest Blinding of observers of outcome to exposure. Search strategies for identifying studies relating to treatment. one being free of the disorder Prognosis Inception cohort.tw.tw. AND blind:.tw.tw. the same one that was retrieved by the search using meta-analysis as a publication type [2].000 citations are retrieved from 1994-September 1997 in MEDLINE.tw. Explode 'sensitivity and specificity' OR explode diagnosis OR sensitivity. MEDLINE has a publication type. OR mortality (as a subheading of the subject) fying all therapy trials.380 Table I. AND value:. or having." Therapy Random allocation of patients to comparison groups Diagnosis Clearly identified comparison groups. or etiology using MEDLINE.tw. ('tw' indicates textword) OR double.tw. a Treatment Combination of terms with best specificity: Combination of terms with best sensitivity: placebo. OR random:. OR drug therapy (as a subheading of the subject) OR therapeutic use (as a subheading of the subject) Diagnosis Combination of terms with best specificity: Combination of terms with best sensitivity: Explode 'sensitivity and specificity' OR predictive. 'practice guidelines'. OR relative.tw.tw.pt. diagnosis. While the MEDLINE searches were successful in locating a relevant article.oxfordjournals. prognosis. Table 2.tw. An alternative search strategy is to determine whether someone has already done all the work for you. and two are about the treatment of head and neck cancer.tw. OR course:. early in the course of the disorder and initially free of the outcome of interest Objective or reproducible assessment of clinically important outcomes Causation Clearly identified comparison group for those at risk of. The Cochrane Library Downloaded from annonc. Reviewing these. Randomized controlled trial. Combining ('ANDing') these with the results of the previous content search reduces the number of citations to 19. AND control. you may be wondering what other electronic resources are available to facilitate locating . EMBASE Excerpta Medica produces a comparable database to MEDLINE that may be more accessible in Europe. particularly for pharmaceutical trials.org by guest on February 6. Guidelines for critical screening of journal articles on clinical research topics. looking for evidence-based practice guidelines based on a current systematic literature review. 16 have to do with esophageal carcinoma.

Double-clicking on this line allows you to see the citations. a broader range of articles encompassing other fields of medical care. A simple search mechanism permits words and terms to be entered for full text searching across all databases. Searching using the term 'mammography' retrieves 126 references. The Cochrane Collaboration also assists the US National Library of Medicine to improve the consistency of indexing randomised controlled trials and controlled clinical trials that are not randomised. the Database of Reviews of Effectiveness (DARE). Unfortunately. written by a clinical expert. and 232 in CCTR.net. This section also lists the protocols for Cochrane systematic reviews under development. Once again. Moreover. was ultimately less costly. 14]. A search for the MeSH term 'chemotherapy. Since 1995. In this case. and sets of citations can be combined using the terms AND and OR. The third section of the Library. Best Evidence only includes studies that are methodologically-sound [12] and summarizes the majority of them using a structured abstract. The Cochrane Library always indicates how many 'hits' there were in each of the four different sections in the top panel of the screen. such as obstetrics and gynecology. a search using Best Evidence is straightforward. A further subclassification appears indicating that one citation is in the 'Abstracts of quality assessed systematic reviews'. and disseminates systematic reviews of randomized trials of many health care interventions. In addition. Turning to the clinical question on mammography. is updated quarterly and contains four bibliographic sections: the Cochrane Database of Systematic Reviews (CDSR).org by guest on February 6. Certain methodological quality criteria have to be met for a systematic review to be included in DARE. This indicates that consensus double reading of mammograms resulted in fewer false positives and false negatives than single reading and. Non-consensus double reading. Updated annually. entering 'head and neck cancer' retrieves no citations in CDSR. The first of the citations in DARE is the El-Sayed metaanalysis article [2]. DARE comprises systematic reviews that have been published outside of the Collaboration. Best Evidence. psychiatry and surgery.medlib. the Cochrane Controlled Trials Registry (CCTR). http://www. The Cochrane Library also has numerous citations concerning breast cancer screening. four citations in DARE. The first of these is the El-Sayed paper [2]. Enter the term 'neoplasms'and then select 'Head and neck neoplasms' from the listing by double-clicking on it. however.au/healthbase/cochrane/intro. double-click on the appropriate line. adjuvant' yields no citations. The Cochrane Library also includes an advanced search engine that allows both textwords and MeSH terms to be used. Best Evidence has articles relating to general internal medicine dating back to 1991. Some articles specifically addressing oncologyrelated issues are also included. Best evidence Another valuable resource for locating high quality studies quickly is Best Evidence.oxfordjournals. on the other hand. For example. because of the reductions in errors. Doubleclicking the reference title reveals the full structured abstract and commentary. have been added. To see the citations in the DARE.htm). four in DARE. each abstract is followed by a commentary. available from the American College of Physicians and BMJ Publishing Group. many of these do not have abstracts available within the Library. contains a growing list of over 160. produced by the Cochrane Collaboration. 2011 . This retrieves 4421 citations. one can begin by clicking on the 'MeSH' button on the advanced search screen. including two that are directly pertinent to the question of improving the yield of screening [13. but also had more false positives and higher costs. The Cochrane Library. some of the citations in DARE lack abstracts.381 high quality studies. though. that is designed to place the study findings into clinical perspective. and the Cochrane Review Methodology Database (CRMD). the CCTR.000 references to therapeutic intervention trials. Searching The Cochrane Library is easy. maintains. the commentary accepts the authors' conclusions that chemotherapy has significantly increased treatment toxicity and only improved survival when used concurrently with local definitive therapy. After clicking on the 'Search' button and entering the textword 'mammography'. it found no citations in the CDSR. led to detection of more tumours than single reading (but not than consensus double reading). one citation is in the 'Other assessed reviews' section.hcn. This is the electronic version of two paper-based abstract journals: ACP Journal Club and Evidence-Based Medicine. Nevertheless. available on CD-ROM from UpDate Software in Oxford. pediatrics. this version includes an independently prepared structured abstract that summarises the methodology and results of the review and indicates that the meta-analysis has some weaknesses. The Cochrane Library is one such resource. CDSR consists of complete reports of Cochrane Collaboration systematic reviews. while two citations appear under 'Other reviews'.com. Best Evidence supports both textword searching (using the 'Search' option) and MeSH term searching (using the index' function). Combining the two sets using the AND function produces a smaller collection of 178 citations. family medicine. Best Evidence provides a listing of 23 citations that include this term. an international organization that prepares. Reviewing the list reveals an article specifically dealing with double reading of mammograms. CDSR is also available via the Internet (http://www. Downloaded from annonc. but not when used as induction treatment. so a textword search using the term 'chemotherapy' is appropriate. Asking the program to 'Explode and search' using this term retrieves 578 citations (using Issue 3 of the 1997 Cochrane Library). To answer the question of the role of neoadjuvant chemotherapy in patients with head and neck cancers. will generally be more useful for answering those patient care questions that are not oncology-specific. and 174 citations in the CCTR.

but their size makes searches for clinically pertinent and sound studies clumsy at best. textbooks are seldom explicit about the evidence or the quality of the evidence used for their recommendations. How to use an article about a diagnostic test. What are the results and will they help me in caring for my patients? Evidence-Based Medicine Working Group. and treatment options. But being familiar with how to use larger bibliographic databases. Textbooks simply cannot keep up with such advances. References 1. Also. 6. cellular classification. Nelson N. Recalling the first clinical scenario.382 Textbooks Finally. J Clin Oncol 1996. such as CANCERLIT. Note. A meta-analysis of prospective and randomized trials. other treatments. a complete description is available. co-morbidity.org by guest on February 6. Dr. If you find yourself managing a condition that you have not dealt with recently. Are the results of the study valid? Evidence-Based Medicine Working Group. Sackett DL Users' guides to the medical literature. the evidence seems clear that adjuvant chemotherapy should not be used for induction for locally advanced head and neck squamous cell carcinoma. a Canadian Network of Centres of Excellence Program). Users guides to the medical literature. Applying the findings One of the harshest criticisms of 'evidence-based medicine' is that it places evidence from research above all in clinical decision making. This is the US National Cancer Institute's cancer information database. should not be relied upon for therapeutic decision making.gov/health. How to use an article about therapy or prevention: B. Hunt is supported by a HEALNet fellowship. It is available on-line and over the Internet (e. The well-built clinical question: A key to evidence-based decisions (Editorial). availability of various treatment options) and the patient's wishes. Information for patients is also available. Guyatt GH. Richardson WS. Adjuvant and adjunctive chemotherapy in the management of squamous cell carcinoma of the head and neck region. New resources like The Cochrane Library and Best Evidence that only include high quality clinical studies and summarize the findings are beginning to improve this process for the fields and types of studies that they cover. 270 (17): 2096-7 4. this database includes information on cancer treatment and screening. is still essential for finding the current best evidence about many clinical questions. such as Scientific American Medicine. and ongoing clinical trials. JAMA 1993. 5. and by selecting the appropriate line. selecting 'oropharyngeal cancer' leads to several documents about oral cavity tumours including diagnostic work-up. being able to quickly locate valid. Users' guides to the medical literature. and many important new studies may have been published in the interim. you may wish to refer to a textbook. staging.nci. Cook DJ. Dr. III. and that consensus duplicate readings of mammograms should be used. These limitations suggest that textbooks. JAMA 1994. Rennie D. 271:59-63. Users' guides to the medical literature. Sackett DL. despite the win-win evidence for consensus duplicate mammogram reading. Conclusion With an ever increasing number of trials evaluating different aspects of medical care. Regularly updated. such as the optimal treatment for a given condition. texts are less useful when it comes to topics for which the evidence can change rapidly. Finding information about a malignancy in PDQ is primitive but efficient. a good choice would be PDQ. El-Sayed S. as well as on CD-ROM. or the mechanism of action of a medication. II. 2011 Acknowledgements This work was supported by the Health Evidence Application and Linkage Network (HEALNet. Nevertheless. for example. 3 Guyatt GH. JAMA 1993. Haynes is supported in part by a National Health Scientist award from the National Health Research and Development Program. This is because the most recent editions of many textbooks are often two to three years out-of-date. is an option. by and large. Hayward RSA. For general medical conditions. Unfortunately. Guyalt G.. Guyatt GH. preferences and rights (15). Texts may also help to broaden the differential diagnosis in more complex cases. Sackett DL. Cook DJ. 123: A12-13.htm). A table lists the types of cancers that are discussed. new investigational drugs.nih. http://wwwicic. 270: 2598-601. Health Canada.g. 14: 83S-47. Nishikawa J. we come to textbooks. These can be very useful for reviewing the pathophysiology of a condition. however. Jaeschke R. ACP J Club 1995. up-to-date information is becoming more and more important. as well as a listing of physicians and organizations involved in cancer care. For oncology-specific topics. CANCERLIT and EMBASE provide access to almost all relevant studies in medicine. Browman is supported by the Cancer Care Ontario Program in Evidence-Based Care. II. an electronic textbook that is updated regularly. This criticism is unfair. General purpose evidence databases such as MEDLINE. it is unlikely to be widely implemented unless payors and managers can be induced to shift resources to permit it. How to use an article about therapy or prevention: A. that the systematic review that we found using CANCERLIT and The Cochrane Library is not mentioned in the references.oxfordjournals. . Unfortunately. Dr. in the scenarios that we began with. however. Downloaded from annonc. Wilson MC. 2. as advocates of evidence-based care have clearly pointed out that clinical decision making includes careful consideration of the clinical circumstances of the patient (including.

13. Haynes RB.mcmaster. Users' guides to the medical literature: VI. BMJ 1996: 312: 71 2. McKibbon K. The value of the second view in screening mammography. III. Sackett DL. Are the results of the study valid? Evidence-Based Medicine Working Group. Haynes Room 3H7. 10. Evidence-Based Medicine Working Group. JAMA 1994. JAMA 1994. Duffy SW. Developing optimal search strategies for detecting clinically sound studies in MEDLINE. Major P et al. Wilczynski N. Oxman AD. B. Warren RM. Wald NJ.383 A. 2011 .A. Received 6 February 1998: accepted 18 February 1998. ACP J Club 1991. 12. UK. Wells G. JAMA 1994.org by guest on February 6. 14. Guyatt GH.ca Downloaded from annonc. 271: 389-91. J Am Med Informatics Assoc 1994. McMaster University Medical Center 1200 Main St W Hamilton Ontario L8N 3Z5 Canada E-mail: bhaynes(nsfhs. Users'guides to the medical literature. Murphy P. Cook DJ. Richardson WS. 114: A18. The origins and aspirations of ACP Journal Club (Editorial). 272: 234-7. How to use an article about a diagnostic test. Correspondence to: Dr. Sackett DL. 15. JAMA 1994. Walker CJ. Laupacis A. B. BMJ 1995. R. Haynes RB. 447-58. Haynes RB. Rosenberg WMC. Bashir S. How to use an overview. 271:703-7. 69: 105-8. Evidence-Based Medicine Working Group. Gray JAM. Tugwell P. 17: 601-5.CCCR multicentre controlled trial of one and two view mammograohy in breast cancer screening. Evidencebased medicine: What it is and what it isn't. 1. Wilczynski NL. How to use an article about prognosis. 311: 1189-93. Jaeschke R.oxfordjournals. Haynes RB. Guyatt GH. Br J Radiol 1996. 272: 1367-71. n. Assessment of methodological search filters in MEDLINE. What are the results and will they help me in caring for my patients? Evidence-Based Medicine Working Group. Users'guides to the medical literature: V. McKibbon KA et al. Proc ANNU Symp Comp Appl Med Care 1994.

Downloaded from annonc.oxfordjournals.org by guest on February 6. 2011 .