title: Systematic review of guidelines for management of intermediate hepatocellular carcinoma using the Appraisal of Guidelines Research and Evaluation II instrument.
abstract: BACKGROUND
  Hepatocellular carcinoma is the second leading cause of cancer-related mortality worldwide. Multiple guidelines have been developed to assist clinicians in its management. We aimed to explore methodological quality of these guidelines focusing on treatment of intermediate hepatocellular carcinoma by transarterial chemoembolization.
  
  
  METHODS
  A systematic search was performed for Clinical Practice Guidelines and Consensus statements for hepatocellular carcinoma management. Guideline quality was appraised using the Appraisal of Guidelines Research and Evaluation II instrument, which rates guideline development processes across 6 domains: 'Scope and purpose', 'Stakeholder involvement', 'Rigour of development', 'Clarity of presentation', 'Applicability' and 'Editorial independence'. Thematic analysis of guidelines was performed to map differences in recommendations.
  
  
  RESULTS
  Quality of 21 included guidelines varied widely, but was overall poor with only one guideline passing the 50% mark on all domains. Key recommendations as (contra)indications and technical aspects were inconsistent between guidelines. Aspects on side effects and health economics were mainly neglected.
  
  
  CONCLUSIONS
  Methodological quality of guidelines on transarterial chemoembolization in hepatocellular carcinoma management is poor. This results in important discrepancies between guideline recommendations, creating confusion in clinical practice. Incorporation of the Appraisal of Guidelines Research and Evaluation II instrument in guideline development may improve quality of future guidelines by increasing focus on methodological aspects.
authors.affiliation: Department of Hepatology and Gastroenterology, Ghent University, Ghent, Belgium.
authors.forename: Tom
authors.initials: T
authors.lastname: Holvoet
authors.affiliation: Department of Hepatology and Gastroenterology, Ghent University, Ghent, Belgium.
authors.forename: Sarah
authors.initials: S
authors.lastname: Raevens
authors.affiliation: Department of Hepatology and Gastroenterology, Ghent University, Ghent, Belgium.
authors.forename: Yves-Paul
authors.initials: YP
authors.lastname: Vandewynckel
authors.affiliation: ERBP, Ghent University Hospital, Ghent, Belgium; Renal Division, Department of Internal Medicine, Ghent University, Ghent, Belgium.
authors.forename: Wim
authors.initials: W
authors.lastname: Van Biesen
authors.affiliation: Department of Hepatology and Gastroenterology, Ghent University, Ghent, Belgium.
authors.forename: Karen
authors.initials: K
authors.lastname: Geboes
authors.affiliation: Department of Hepatology and Gastroenterology, Ghent University, Ghent, Belgium. Electronic address: Hans.VanVlierberghe@UGent.be.
authors.forename: Hans
authors.initials: H
authors.lastname: Van Vlierberghe
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000628:therapy*; D016461:Chemoembolization, Therapeutic; D019468:Disease Management; D019317:Evidence-Based Medicine; D006801:Humans; D008113:Liver Neoplasms / Q000628:therapy*; D017410:Practice Guidelines as Topic / Q000592:standards*
keywords: Appraisal of Guidelines Research and Evaluation II instrument; Clinical practice guidelines; Hepatocellular carcinoma; Transarterial chemoembolization