A Norwegian perspective on the Swedish national guidelines on prostate cancer for non-metastatic disease.

Almost two decades ago, Wiking Månsson reviewed the state of urological guidelines in an editorial in European Urology titled ‘Evidence-Based Urology – A Utopia?’ [1]. In his article, he posed the question: How are we doing in urology? and provided the rather unflattering answer: Not that good. He lamented that ‘...most of what is published in the urological journals has low level of evidence and as a consequence, low grade of recommendation’. A lot has changed since Månsson voiced his dismay and the change has mostly been for the better. Today, urological guidelines are based on a large number of randomized clinical trials and high-quality register studies. We can, with considerable pride, state that prostate cancer researchers from Scandinavia, with Sweden often in the lead, have made decisive contributions to these improvements. The Scandinavian Prostate Cancer Group (SPCG) has been the incubator of the major Nordic randomized trials, with SPCG-4 and SPCG-7 as the most widely known trials [2,3]. Furthermore, the National Prostate Cancer Register, a Swedish population-based, clinical register, has generated multiple high impact publications [4,5]. Clinical cancer registers are cost-efficient tools to study the often decade-long prostate cancer disease trajectory. In Scandinavia in general and in Sweden in particular, there is a strong scientific environment that has enabled the creation of evidence-based urological cancer guidelines. Clinical guidelines are formulated according to standard procedure, based on a transparent methodology, discussed in professional panels including representatives from other relevant professions and patient organizations. Modern guidelines are largely based on clinical evidence, with prospective randomized control trials having the highest, and retrospective studies from single institutions having the lowest impact. Changes in guidelines can have major implications for patient management, organization of the health care system and on health care economy. However, due to the high level of evidence required for strong recommendations, changes are often slow in the coming. In Europe, most countries adhere to the European Urological Association (EAU) guidelines [6]. While the recommendations in the EAU Guidelines are based on strict rules, the implementation has to be flexible since the health care systems and ‘health care culture’ varies to a certain degree across Europe. In some European countries, urologists and oncologists have adopted EAU guidelines as their own guidelines, while in other countries national guidelines have been issued. In contrast to the EAU guidelines, National guidelines can be written to suit the specific requirements, opportunities and limitations of a national health care system. For the first time a summary of the Swedish prostate cancer guidelines is published in English by Bratt et al. in this issue of the Scandinavian Journal of Urology [7]. Why is it important guidelines written by Swedish urologists and oncologists are published in an international scientific journal? It is important for several reasons: First, despite universally available publications of randomized and other important clinical trials, the interpretation of the evidence presented in these trials can vary substantially. Publication ensures that the selection of studies and their interpretation in the formulation of the guidelines are transparent. Furthermore, publication of national guidelines in peerreviewed journals opens for scrutiny, scientific discussion and criticism which in turn may lead to improvements of both the national and possibly, by way of inspiration and reflection, international guidelines, thus, leading to the development of ‘collective intelligence’. The current Swedish guidelines contain inspiring innovations and some notable deviations from international guidelines. On the innovative side, we take notice that ongoing and relevant clinical trials are listed in the summary of