In my mailbox, I received the latest ACR journal picks and as always, Dr. Recht makes some great insights. Here is what he says: There is often very limited evidence, especially from randomized trials, for many important decisions faced in the clinic . This is especially true for technical aspects of radiation therapy. Thus, panels tasked with creating clinical practice guidelines frequently must decide between stating that there are insufficient data to make concrete recommendations or making recommendations based on consensus among the members, realizing the lack of evidence but wanting to give "reasonable" answers to the perplexed. The first alternative tends to make the guideline sponsor and the intended audience unhappy. The second runs the risk that the imprimatur of a major professional society may give tentative recommendations excessive authority in the minds of practitioners or third parties (such as health insurers) by making it seem that a question is settled. The two articles selected this month illustrate how different conclusions can arise from choosing between these philosophical and methodologic choices. Smith and colleagues updated the ASTRO whole-breast irradiation (WBI) guideline published in 2011 . They also added recommendations regarding the use of a boost and many technical issues not discussed before. The second article, by myself and colleagues, was created in reaction to the ASTRO guideline. It reflects our belief that there was inadequate evidence for many recommendations and that the guideline did not consider plausible (and widely-used) alternative approaches. In my naivete, I thought that guidelines were good, but little did I know there is some push back on this through out medicine. Article here : The Need to Systematically Evaluate Clinical Practice Guidelines Dr. Vinay Prasad also has been calling attention to this issue and clinical trial problems in general. A little snippet can be found here: Vinay Prasad, MD, on 'Medical Reversal' I am not taking a position nor endorsing any side (nor any of the above linked articles). I am just putting it out there for discussion. Quite frankly we all feel the tension of ourselves being highly trained authorities that are tested to death and then having to further submit to guidelines we don't necessarily agree with. With that said, I'm sure we all love guidelines too b/c a lot of them are very good.