Finding a needle in a haystack: The identification of clinical practice guidelines for psychosocial oncology through an environmental scan of the academic and gray literature

Abstract Objective Clinical practice guidelines (CPGs) are evidence‐based tools well‐suited to translate the latest research evidence into recommendations for routine clinical care. Given the rapid expansion of psychosocial oncology research, they represent a key opportunity for informing the treatment decisions of overburdened clinicians, standardizing service delivery, and improving patient‐reported outcomes. Yet, there is little consensus on how clinicians can most effectively access these tools and little to no information on the current availability and scope of CPGs for the range of psychosocial symptoms and concerns experienced by patients with cancer. Method Our environmental scan consisted of an academic and gray literature designed to identify currently available CPGs addressing a range of cancer‐related psychosocial symptoms. Results Findings revealed a total of 23 existing psychosocial oncology CPGs that met full eligibility criteria. The gray literature search was found to be more effective at identifying CPGs (n = 22) compared to the academic search (n = 9). Conclusion Several concerns arose from the systematic search. The limited publication of CPGs in peer‐reviewed journals may make clinicians and stakeholders more hesitant to implement CPGs due to uncertainties about the methodological rigor of the development process. Further, many existing CPGs are outdated or failed to be updated according to guideline recommendations, meaning that the recommendations may fall short of their purpose to translate up‐to‐date research findings. Future directions Future research should seek to systematically assess the quality of existing psychosocial oncology CPGs and shed light on the current state of implementation and adherence in clinical practice in order to better inform guideline developers on the current needs of the psychosocial oncology community.


| INTRODUCTION
Cancer is one of the leading causes of death across the world, with as many as 19.3 million new cases diagnosed worldwide in 2020 alone. 1As incidence rates are expected to rise by nearly 60% over the next 20 years, 2 the burden of this disease will also increase, with an unprecedented number of individuals, families, and communities facing not only the associated physical ailments and escalating costs incurred by healthcare systems, but also a wide range of psychological, social, and occupational challenges. 2,3ommon psychosocial symptoms reported by patients with cancer include overall psychological distress, [4][5][6] symptoms of depression 6,7 and anxiety, 6,8 demoralization, 9 interpersonal difficulties, 5,10 and reduced quality of life. 11n 2007, the US Institute of Medicine recommended that treating psychosocial symptoms in patients with cancer is best practice for comprehensive cancer care.12,13 This assertion has been widely endorsed, as evidenced by the rapid advances in the availability of new psychosocial oncology services, upsurges in relevant peer-reviewed articles, care standards, and reports, and the development of new interventions.2,14 The rapid expansion of psychosocial oncology poses a challenge for clinicians providing day-to-day clinical care.Psychosocial oncology clinicians experience large caseloads, have limited time for selecting and reviewing relevant scientific literature, and might have limited capacity to translate empirical knowledge into practical interventions to be delivered at the point of care.[15][16][17] Clinical practice guidelines (CPGs) are well-suited to bridge the gap between scholarly knowledge and service delivery.CPGs are systematically developed tools designed to summarize the latest scientific evidence and provide clinically applicable recommendations to inform treatment decisions for various health conditions. 18 CPs targeting psychosocial symptoms for patients with cancer provide recommendations based on the latest scientific findings for clinical care at all stages of the cancer care continuum, from screening to treatment and follow-up, and also help standardize service offerings and optimize the use of often limited resources.[19][20][21] Yet, little is known about the current scope and accessibility of CPGs in psychosocial oncology.Currently, there is no universally accessible, comprehensive repository for CPGs, which makes it difficult for clinician to find and access such evidence-based documents.While some CPGs may be accessible through "traditional" academic sources (e.g., PubMed database), clinicians may lack institutional access to databases depending on their work settings.Further, some CPGs are not indexed in academic databases and can only be accessed through noncommercial sources.22 For example, certain special interest groups and government-funded organizations only publish their CPGs on their organizational websites.

| Study objective
To bridge this knowledge gap, we conducted an environmental scan to identify the number and scope of clinical practice guidelines that target the psychosocial symptoms of individuals diagnosed with cancer across the cancer care trajectory and examine their accessibility through different search methods.

| Procedures
An environmental scan is a type of review that encompasses both published literature (e.g., peer-reviewed articles) and unpublished or informally published documents. 23We selected this review method to increase the likelihood of identifying existing psychosocial oncology CPGs, which are often uploaded onto institutional or organizational websites by their developers.Our environmental scan was informed by the recommendations for systematic reviews for CPGs outlined by Johnston et al. 22 We included two separate systematic searches to review (a) the academic literature and (b) the "gray" literature.Initial searches were conducted from January 2023 to February 2023 and updated in July 2023.

| Inclusion and exclusion criteria
Eligibility criteria were established in two steps.First, we identified relevant CPGs based on methodological characteristics, as per the National Guidelines Clearinghouse 2013 revised criteria 24   Relevant keywords for each applicable PICAR component were identified through a review of the literature on psychosocial oncology care and in consultation with experts and our research team.Keywords were utilized as either free-text or MeSH terms (if available) and paired with Boolean operators.To maximize the retrieval of relevant results and ensure a comprehensive search, spelling variations were included through database-specific truncation and search settings were set to identify keywords in all text (i.e., titles, abstracts, subject heading, full text, etc.).Results were filtered by language to include only English results and by publication type (i.e., guideline) when applicable.See Appendix, Table A1 for the electronic search strategy for each database.

| Gray literature search
The gray literature search included a multistep approach.
Step 1 consisted of a generic Internet search using the Google search engine through the Google Chrome browser.Based on recommendations for limiting methodinherent selection bias, cookies and search history were cleared from the browser prior to conducting the search. 27,28Keywords and search terms from the academic search were adapted for the generic Internet search.Step 2 consisted of a Google Scholar search, which indexes both peer-reviewed and gray literature resources. 28Keywords and search terms from the academic search were used to generate relevant search strings and searched within both "full text" and "title" using the advanced search functions.
Step 3 consisted of a targeted Internet search for CPGs through the official websites of organizations, groups, agencies, and government bodies involved in psychosocial oncology or guideline development.The identification of relevant websites was informed by our literature search and consultation with our research team as well as domain experts.We consulted the websites of the following organizations: the National Comprehensive Cancer Network (NCCN; https:// www.nccn.org/ ), the Canadian Association of Psychosocial Oncology (CAPO; https:// www.capo.ca/ ), Cancer Care Ontario (CCO; https:// www.cance rcare ontar io.ca/ en), the European Society for Medical Oncology (ESMO; https:// www.esmo.org/ ), the American Society of Clinical Oncology (ASCO; https:// www.asco.org/ ), the American Psychosocial Oncology Society (APOS; https:// apos-socie ty.org/ ), and the International Psycho-Oncology Society (IPOS; https:// www.ipos-socie ty.org/ ).

| Identification and data extraction
All results generated from the academic and targeted Internet search were retained.As both the generic Internet search and Google Scholar search were expected to produce more results than was feasible to screen, we followed the recommendation by Haddaway et al. 28 to limit screening to the first 300 results for each search string (i.e., 30 pages).Results were imported into Zotero 6.0.22,deduplicated, and screened for eligibility.An initial screening of titles and abstracts was conducted, followed by a full-text screening.If multiple versions of a CPG were identified, only the latest version of the CPG was retained for review.Following identification, data extracted from guidelines included: developer, location, psychosocial symptoms/concerns addressed, target population (age and cancer type), and stage of care.CPG identification and data extraction was independently conducted by two reviewers.All disagreements between the reviewers were recorded and discussed until consensus was reached.

| Screening and reliability
Two reviewers independently screened the results from all search methods based on the eligibility criteria described above and identified a total of 35 psychosocial oncology CPGs.Following a consensus meeting, 14 disagreements in identification resulted in 12 excluded records and two determined to meet full eligibility criteria.Reasons for exclusion were insufficient relevance to psychosocial oncology (n = 7), no evidence for the use of systematic methods to develop treatment recommendations (n = 4), and availability of a more up-to-date version (n = 1).Reliability at the full-text review stage was excellent 29 between the two reviewers (Cohen's κ = 0.88).

| Clinical practice guideline identification
A total of 10,423 initial records were generated by the various search methods employed in this study.Prior to screening and deduplication, five records were flagged by Retraction Watch and removed.The listed reasons for retraction included: copyright claims (n = 1), self-plagiarism (n = 1), errors in the data (n = 1), problems with the results (n = 2), objections by a third party (n = 1), and withdrawal (n = 1).A total of 218 records were retained for a full-text review.Based on both the methodological and PICAR eligibility criteria, 195 records were excluded following a full-text review and reviewer consensus meetings.In total, 23 records were deemed eligible and identified as psychosocial oncology CPGs.Refer to Table 1 for a complete list of all identified CPGs.Additionally, a PRISMA flow diagram detailing the CPG selection process can be found in Figure 1.
The academic literature search yielded a total of 7498 relevant hits and identified 9 CPGs that met full eligibility criteria, only 1 of which were unique to this search (i.e., not identified by any other search method).In contrast, the gray literature search generated 2925 records and identified a total of 22 CPGs, 14 of which were unique to this search.Differences emerged between the three different types of gray literature searches.First, the targeted Internet search yielded 860 records and identified 21 CPGs in total, 1 of which was unique to this search.Next, the naïve Google search yielded 1098 records and identified 16 CPGs overall, 1 of which was unique to the search.Lastly, the Google Scholar search generated 900 records and identified 6 CPGs, all of which were also identified by another search.Refer to

| DISCUSSION
Clinical practice guidelines are essential tools for quality healthcare provision and clinical practice.1][32] The current study identified 23 up-to-date CPGs that provide recommendations for non-pharmacological interventions in the treatment of the psychosocial symptoms of individuals diagnosed with cancer.Results revealed the academic literature search to be less efficient than the gray literature search at identifying CPGs, as evidenced by yielding fewer CPGs despite generating the highest number of relevant hits prior to screening.In contrast, the gray literature search yielded a greater number of CPGs missed by the academic search and identified all but one of the psychosocial oncology CPGs.In terms of the different gray literature search methods, the targeted Internet search was the most effective, identifying the greatest number of overall and unique CPGs.This suggests that clinicians looking for psychosocial oncology CPGs do not need to conduct a thorough, time-consuming academic search; rather, they will be best served by conducting a targeted search through the websites of key organizations and special interest groups.The efficiency of this search method is especially important given its widespread accessibility and time effectiveness.However, our findings also highlight some key concerns regarding the current state of psychosocial oncology CPGs as evidence-based tools.
The accessibility of CPGs through the gray literature search is encouraging when considering that clinicians report more using informal search methods to find information and tools more frequently than academic databases. 33However, an Internet search alone may not be sufficient.Our academic search identified several CPGs not detected by the gray literature search, meaning that even effective informal search methods may fail to identify relevant CPGs identifiable through a complementary database search.Yet, there are several barriers to conducting this type of search.Due to the high number of records generated, it would require a significant investment of time on the part of clinicians, who often face high work demands and lack time to conduct such a search.Further, even if clinicians were able and willing to conduct a database search, they are more likely to run the risk of identifying outdated versions of existing CPGs.Previously, clinicians could refer to the National Guidelines Clearinghouse (NGC)-a federally funded resource -which served as a repository for all CPGs.However, NGC is no longer operative due to loss funding in 2018. 34Since then, no new online repository for CPGs has been established.An online hub for all currently available CPGs, including psychosocial oncology CPGs, would play an essential role in addressing these barriers and ensuring ease of access for clinicians to a variety of CPGs ranging in focus (e.g., targeting a specific symptom or providing more global care recommendations), organization of origin, country of development, and methods of assessing evidence.
The limited availability of up-to-date CPGs through peer-reviewed sources also raises concerns about their quality.The peer-review component of journal publication allows for additional independent appraisal and oversight into CPG development, providing an opportunity for improvements to the guideline content and recommendations prior to publication. 35 independent, external assessment of the quality and methodological rigor, it is unclear whether encouraging the use of these CPGs represents a step towards evidence-based practice and optimal patient care.As such, even if many of these CPGs are easily accessible, clinicians may face a dilemma where they wish to be more evidence-based in their practice but are unsure about the quality and/or applicability of the CPGs they find.Thus, implementation and adherence of CPGs may be well-served by publication in a peer-reviewed journal, given their function as a form of "quality control" for many institutions, clinicians, or other stakeholders.Yet, guideline developers may neglect to publish newly developed or updated CPGs in peer-reviewed journals for a variety of reasons.For example, the formulation of recommendations by the guideline development team emerged from an extensive review process by content experts; peer-reviewers and editors may be unaware of the full range of considerations and, consequently, suggested changes and edits to recommendations may fail to account for the full scope of relevant information.In addition, engaging in the peer-review process is timeconsuming and significant time delays between each stage of submission and revision may result in the findings and recommendations of the CPG already being outdated by the time it is published. 35he risk of outdated guidelines is a more overarching concern.The most common reason for exclusion in our study was due to guidelines failing to be updated or revised within the past 10 years, meaning that recommendations will often fail to translate the latest empirical findings. 356][37] This limits their applicability as guides for bridging the science-practice gap.Even a high quality and helpful CPG is no longer well-suited for use as an evidence-based tool if its findings are outdated, despite the large amounts of financial and non-financial resources invested into its conception and development. 38he lack of updating also increases the risk that resources ) indicate that only an outdated version of the CPG was found despite the availability of a newer version.
a CPGs are numbered based on order in Table 1.
will be invested into the creation of new CPGs by different organizations, thus duplicating the previous work of guidelines development teams.While some government-funded organizations have enough resources to adhere to more rigorous and structured updating procedures (e.g., the National Comprehensive Cancer Network (NCCN)), it is important to acknowledge many institutions face important barriers to the regular appraisal and updating of existing CPGs. 38

| Limitations
This CPG environmental scan includes several limitations.All identified CPGs were developed by Western organizations in high-income countries (North America and Europe).Although there were no geographical constraints on the search, this might be a consequence of restricting search results to English language results only.Consequently, the recommendations of the CPGs identified most likely reflect the cultural norms of these countries and are designed for application within their healthcare systems and cultural contexts, which could limit their usefulness for clinicians practicing in different countries.Although various organizations have spearheaded efforts to produce CPG adaptations to address the specific needs of their regions, 39,40 the identification of such adaptation was beyond the scope of this study.There may also be additional psychosocial oncology CPGs not accessible through the methodology used herein.Clinicians working in psychosocial oncology settings may have exclusive access to CPGs through their own professional networks and resources (e.g., CPGs developed for exclusive use by employees of a particular hospital network).As such, the current findings may not reflect the psychosocial oncology CPGs most directly accessed or used by clinicians.

| Future directions and conclusions
Our findings suggest that psychosocial oncology CPGs address a wide range of symptoms and concerns, are accessible to clinicians, and can be found through even informal search methods.Several concerns about the utility of these CPGs as evidence-based tools arose.Most notably, many existing psychosocial oncology CPGs fail to be updated following their initial publication and little information is available about their quality.Future research should seek to evaluate the methodological quality of currently available psychosocial oncology CPGs.In addition, our findings do not inform us on the current state of CPG use by clinicians providing psychosocial care to individuals diagnosed with cancer.Previous research found that clinicians often do not integrate evidence-based interventions into their service delivery and report limited knowledge about CPGs as a whole. 38,41A more in-depth understanding of the current clinical use and implementation of psychosocial oncology CPGs would more effectively address barriers to their use and further support efforts to mobilize resources to keep CPGs up-to-date.

2. 3 |
Search strategy 2.3.1 | Academic literature search This search consisted of a systematic search of five peerreviewed academic databases (PubMed, Medline, JSTOR, PsycINFO, and Clinical Key) and was developed in consultation with a research librarian at McGill University.
Table 2 for a visual representation of the identification of each CPG by the different search methods.
Characteristics of all identified psychosocial oncology clinical practice guidelines (CPGs).
T A B L E 1 Without an

) a Academic literature search Gray literature search: naïve Google search Gray literature search: targeted internet search Gray literature search: Google
Identification of psychosocial oncology clinical practice guidelines (CPGs) by each search method.
T A B L E 2