Primary and metastatic brain tumours in adults: summary of NICE guidanceBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k2924 (Published 17 July 2018) Cite this as: BMJ 2018;362:k2924
All rapid responses
It was with great interest that I read the NICE Guideline NG99 ‘Brain tumours (primary) and brain metastases in adults’ . I was therefore glad to see that The BMJ decided to publish summary guidance  with a large emphasis on managing late effects which will hopefully be seen by the large number of your readership involved in primary care. I was also excited by the numerous positive recommendations such as the increased availability of 5-ALA, intraoperative imaging, stereotactic radiosurgery and awake craniotomy. All of these are welcome and will no doubt have a positive impact on the survival and quality of life of patients. I therefore commend the wider guideline team on this excellent piece of work.
I was however, upon reading the summary guidance, puzzled to see that in the prominently placed ‘What’s new in this guidance’ box that top billing was given to not allowing tumour treating fields (TTF). Whilst I agree with the recommendation, going further to argue that there are questions around both cost-effectiveness and clinical-effectiveness, I found it very odd that the authors decided to highlight this particular part of the guideline. TTF has never been widely available on the NHS and if available at all this would be in extremely limited numbers. Reading through the guideline I see numerous examples of recommendations more suited to the top spot which also match a more literal interpretation of ‘what’s new’. NICE themselves highlighted 5-ALA as the headline recommendation in their press release with no or very limited mention of TTFs.
This did raise my suspicions and having tried to contact the lead author, a ‘current employee’ of the National Guideline Alliance (NGA), I was informed he had not worked there since April 2018. Further investigation through a publically available Linkedin profile [reference omitted] I find he is an employee of FIECON , a health economics consultancy and had been prior to the publication of the guideline and at the very least at the time of approval of the final draft BMJ manuscript. I am extremely concerned that this has been omitted from the competing interests in both the article and the linked, more thorough, NICE declarations  whilst I would argue less relevant ones have been prominently included. The phrase ‘are employees of the National Guideline Alliance’ in the funding section of the summary guidance would also be untrue at the time of approval of the final manuscript.
I emailed the BMJ and unsuccessfully the lead author to ask that this potential competing interest be disclosed. I thought a short sentence the end of the summary guidance would be sufficient. I always have concerns about competing interests from consultancy firms as it is nearly impossible to identify who they have accepted money from. I gave the authors at the time the benefit of the doubt and assumed that this consultancy were not working with any firms in conflict with the clinical areas or technologies considered by the guideline and that omission of this competing interest, whilst serious, was perhaps understandable.
Following the authors’ unwillingness to declare this interest I decided to explore this further. It took me less than five minutes through internet searches to find that FIECON has recently had an advisory role with Tesaro for the drug niraparib for use in patients with recurrent ovarian cancer  the patient group for which pilot studies are currently investigating the use of TTFs. I am sure further investigation would have bought up other potential conflicts. I do not know if these competing interests changed the content or style of the summary guidance but a reasonable person could believe there is a potential for such.
Whilst it appears this did not impact upon the main NICE guideline there is a clear competing interest during the production of the summary guidance. I believe it is important this is highlighted to other readers and is my primary motivation for writing this rapid response.
Michael Aniston, Retired
 Vergote I, von Moos R, Manso L et al ‘Tumor Treating Fields in combination with paclitaxel in recurrent ovarian carcinoma: Results of the INNOVATE pilot study’ Gynecologic Oncology (2018) doi: 10.1016/j.ygyno.2018.07.018.
Competing interests: Shareholder in Shire, a pharmaceutical company. To the best of my knowledge they are not involved in any clinical area relevant to this summary guidance or the wider NICE guideline.