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## Complete Summary

#### GUIDELINE TITLE

Follow-up of non-small cell lung cancer.

#### BIBLIOGRAPHIC SOURCE(S)

Thomas WW Jr, Komaki RU, Gewanter RM, Gopal RS, Movas B, Rosenzweig KE,
Weisenberger TH, Wolkov HB, Kaiser LR, Mauch PM, Schiller JH, Expert
Panel on Radiation Oncology\--Lung Work Group. Follow-up of non-small
cell lung cancer. Reston (VA): American College of Radiology (ACR);
2005. 6 p. \[23 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previously published version: Sause WT, Byhardt RW, Curran
WJ Jr, Fuller D, Graham MV, Ko B, Komaki R, Weisenburger TH, Kaiser LR,
Leibel SA, Brown RC. Follow-up of non-small cell lung cancer. American
College of Radiology. ACR Appropriateness Criteria. Radiology. 2000
Jun;215 Suppl:1363-72.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Non-small cell lung cancer

#### GUIDELINE CATEGORY

Evaluation

#### CLINICAL SPECIALTY

Nuclear Medicine\
Oncology\
Pulmonary Medicine\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of radiologic procedures for the
follow-up of non-small cell lung cancer

#### TARGET POPULATION

Patients with non-small cell lung cancer

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Frequency of follow-up

2.  Chest X-ray

3.  Computed tomography (CT)

    -   Single postoperative scan

    -   Post treatment scan

4.  Computed tomography of brain

5.  Magnetic resonance imaging (MRI) of brain

6.  3-day pooled sputum cytologies

7.  Nuclear medicine (NUC), bone scan

8.  Positron emission tomography (PET)

9.  Serum tumor markers (tissue polypeptide antigen \[TPA\],
    neuron-specific enolase \[NSE\])

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in the follow-up of patients with
non-small cell lung cancer

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals, and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by the participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1 to 9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by this Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

An analysis in 563 patients with curative resection who were followed
for 10 years with regular clinic visits and chest radiography found that
only 3.8% of patients were able to undergo a second curative resection
based on this program. The calculated cost per life-year gained was
approximately \$75,000. This cost was far above other large-scale
surveillance programs in their country, and the intensity and duration
of follow-up were reduced.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Follow-up Non-Small Cell Lung Cancer**

**Variant 1: Middle aged patient, 3 months postoperative for stage II
squamous cell cancer of lung, asymptomatic. Still smoking, KPS 90-100.**

+-------------------+---------------+---------------------------------+
| **Radiologic Exam | **Ap          | **Comments**                    |
| Procedure**       | propriateness |                                 |
|                   | Rating**      |                                 |
+===================+===============+=================================+
| Frequency of      | 8             |                                 |
| follow-up         |               |                                 |
|                   |               |                                 |
| Every 2-4 months  |               |                                 |
| for 2 years, then |               |                                 |
| every 6 months    |               |                                 |
| until 5^th^ year, |               |                                 |
| then yearly for   |               |                                 |
| life              |               |                                 |
+-------------------+---------------+---------------------------------+
| X-ray, chest      | 8             |                                 |
|                   |               |                                 |
| Every 6 months    |               |                                 |
| for 5 years, then |               |                                 |
| yearly for life   |               |                                 |
+-------------------+---------------+---------------------------------+
| CT, chest         | 8             | The frequency of follow-up CT   |
|                   |               | scans is controversial and may  |
| Single            |               | be impacted by many clinical    |
| postoperative     |               | factors. Chest CT may replace a |
| scan, then yearly |               | routine chest x-ray.            |
| for life          |               |                                 |
+-------------------+---------------+---------------------------------+
| CT, brain         | 2             |                                 |
+-------------------+---------------+---------------------------------+
| MRI, brain        | 2             |                                 |
+-------------------+---------------+---------------------------------+
| 3-day pooled      | 2             |                                 |
| sputum cytologies |               |                                 |
+-------------------+---------------+---------------------------------+
| NUC, bone scan    | 2             |                                 |
+-------------------+---------------+---------------------------------+
| PET               | 2             |                                 |
+-------------------+---------------+---------------------------------+
| Serum tumor       | 2             |                                 |
| markers (TPA,     |               |                                 |
| NSE)              |               |                                 |
+-------------------+---------------+---------------------------------+
| *                 |               |                                 |
| **Appropriateness |               |                                 |
| Criteria Scale*\  |               |                                 |
| 1 2 3 4 5 6 7 8   |               |                                 |
| 9\                |               |                                 |
| 1 = Least         |               |                                 |
| appropriate 9 =   |               |                                 |
| Most              |               |                                 |
| appropriate**     |               |                                 |
+-------------------+---------------+---------------------------------+

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: Elderly patient, never smoked, postoperative 3 months
neoadjuvant chemotherapy irradiation and surgery for stage IIIA
adenocarcinoma of lung. No residual disease at surgery. KPS 80.**

+-------------------+---------------+---------------------------------+
| **Radiologic Exam | **Ap          | **Comments**                    |
| Procedure**       | propriateness |                                 |
|                   | Rating**      |                                 |
+===================+===============+=================================+
| Frequency of      | 8             |                                 |
| follow-up         |               |                                 |
|                   |               |                                 |
| Every 2-4 months  |               |                                 |
| for 2 years, then |               |                                 |
| every 6 months    |               |                                 |
| until 5th year,   |               |                                 |
| then yearly for   |               |                                 |
| life              |               |                                 |
+-------------------+---------------+---------------------------------+
| X-ray, chest      | 8             |                                 |
|                   |               |                                 |
| Every 6 months    |               |                                 |
| for 5 years, then |               |                                 |
| yearly for life   |               |                                 |
+-------------------+---------------+---------------------------------+
| CT, chest         | 8             | The frequency of follow-up CT   |
|                   |               | scans is controversial and may  |
| Single            |               | be impacted by many clinical    |
| postoperative     |               | factors. Chest CT may replace a |
| scan, then yearly |               | routine chest x-ray.            |
| for life          |               |                                 |
+-------------------+---------------+---------------------------------+
| CT, brain         | 2             |                                 |
+-------------------+---------------+---------------------------------+
| MRI, brain        | 2             |                                 |
+-------------------+---------------+---------------------------------+
| 3-day pooled      | 2             |                                 |
| sputum cytologies |               |                                 |
+-------------------+---------------+---------------------------------+
| NUC, bone scan    | 2             |                                 |
+-------------------+---------------+---------------------------------+
| PET               | 2             |                                 |
+-------------------+---------------+---------------------------------+
| Serum tumor       | 2             |                                 |
| markers (TPA,     |               |                                 |
| NSE)              |               |                                 |
+-------------------+---------------+---------------------------------+
| *                 |               |                                 |
| **Appropriateness |               |                                 |
| Criteria Scale*\  |               |                                 |
| 1 2 3 4 5 6 7 8   |               |                                 |
| 9\                |               |                                 |
| 1 = Least         |               |                                 |
| appropriate 9 =   |               |                                 |
| Most              |               |                                 |
| appropriate**     |               |                                 |
+-------------------+---------------+---------------------------------+

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: Middle aged patient, heavy smoker, unresectable stage 3A
adenocarcinoma. Treated with concurrent chemoradiotherapy to 66 Gy using
conformal technique.**

+-------------------+---------------+---------------------------------+
| **Radiologic Exam | **Ap          | **Comments**                    |
| Procedure**       | propriateness |                                 |
|                   | Rating**      |                                 |
+===================+===============+=================================+
| Frequency of      | 8             |                                 |
| follow-up         |               |                                 |
|                   |               |                                 |
| Every 2-4 months  |               |                                 |
| for 2 years, then |               |                                 |
| every 6 months    |               |                                 |
| until 5^th^ year, |               |                                 |
| then yearly for   |               |                                 |
| life              |               |                                 |
+-------------------+---------------+---------------------------------+
| X-ray, chest      | 8             |                                 |
|                   |               |                                 |
| Every 6 months    |               |                                 |
| for 5 years, then |               |                                 |
| yearly for life   |               |                                 |
+-------------------+---------------+---------------------------------+
| CT, chest         | 5             | The frequency of follow-up CT   |
|                   |               | scans is controversial and may  |
| Post treatment    |               | be impacted by many clinical    |
| scan, then every  |               | factors. Chest CT may replace a |
| 6 months for 5    |               | routine chest x-ray. The value  |
| years, then       |               | of post-therapy screening       |
| yearly for life   |               | should be discussed with the    |
|                   |               | patient.                        |
+-------------------+---------------+---------------------------------+
| PET               | 4             | This modality is currently      |
|                   |               | under study and may be impacted |
| One after         |               | by many clinical factors. The   |
| treatment only    |               | value of post-therapy screening |
|                   |               | should be discussed with the    |
|                   |               | patient.                        |
+-------------------+---------------+---------------------------------+
| CT, brain         | 2             |                                 |
+-------------------+---------------+---------------------------------+
| MRI, brain        | 2             |                                 |
+-------------------+---------------+---------------------------------+
| 3-day pooled      | 2             |                                 |
| sputum cytologies |               |                                 |
+-------------------+---------------+---------------------------------+
| NUC, bone scan    | 2             |                                 |
+-------------------+---------------+---------------------------------+
| Serum tumor       | 2             |                                 |
| markers (TPA,     |               |                                 |
| NSE)              |               |                                 |
+-------------------+---------------+---------------------------------+
| *                 |               |                                 |
| **Appropriateness |               |                                 |
| Criteria Scale*\  |               |                                 |
| 1 2 3 4 5 6 7 8   |               |                                 |
| 9\                |               |                                 |
| 1 = Least         |               |                                 |
| appropriate 9 =   |               |                                 |
| Most              |               |                                 |
| appropriate**     |               |                                 |
+-------------------+---------------+---------------------------------+

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

New technologies are being introduced into the follow-up of patients
with non-small cell lung cancer (NSCLC) at a rapid pace. Very few of
these have been examined in a scientifically justified and
cost-effective manner. Nevertheless, their impact on day-to-day oncology
practice is undeniable. This section examines the evidence supporting or
refuting their integration into the current follow-up recommendations.
It is important to stress that many of these technologies are
unquestionably valuable in assessing symptomatic patients with
recurrence after initial treatment. The relevant question is whether and
how they should be used in routine follow-up of the asymptomatic patient
after primary curative treatment of NSCLC.

**Rationale for Follow-up Recommendations**

Despite the proliferation of treatment options including surgery,
chemotherapy, post-operative chemotherapy, pre-operative
chemoradiotherapy, and primary chemoradiotherapy, the patterns of
failure remain relatively unchanged; many patients fail in the first 2
years post-therapy, long term survival percentages are often under 50%,
salvage interventions are less efficacious than the initial therapy, and
second primary cancers including metachronous lung cancers are common
among long-term survivors. For example, one study reviewed a single
institution experience of 743 resected patients for NSCLC and found only
43 with isolated locoregional recurrence. The median time to recurrence
was 13.6 months and the most frequent site of recurrence was mediastinal
nodes in 49% of recurrences. Only two were treated with re-resection.
Median survival after diagnosis of recurrence was 10.5 months and median
time to distant recurrence after locoregional recurrence was 8.4 months.
For the purposes of this report, one can segment follow-up discussions
into recommendations for postoperative patients and those with therapy
for unresectable cancer.

One might expect the best outcomes among patients treated with surgery,
such that incrementally more rigorous follow-up might be expected to
enhance survival. The justification for this assumption is
controversial. One study evaluated 130 patients divided retrospectively
into routine versus symptomatic follow-up regimens after curative
resection. Most patients\' recurrences were diagnosed based on symptoms
rather than routine tests. Survivals of patients with recurrent cancer
were poor and unaffected by follow-up regimen. The authors questioned
the value of routine follow-up imaging based on these data. Another
study retrospectively evaluated 124 patients with resected NSCLC using
physical examination and chest radiography every 3 months for 2 years
and every 6 months for an additional 3 years. Annual chest CT scans were
done. Only 14 patients with second malignant tumors could be treated
surgically, and 9 of these were alive and without evidence of disease at
a median of 20 months follow-up. The median size of resected tumors was
14 mm. The authors also concluded that locally recurrent lung cancers
are infrequently resectable. Another study followed postoperative
patients with physical examination and chest x-ray every 3 months,
fiberoptic bronchoscopy and chest and abdominal CT scans every 6 months.
Recurrence was found in 71% of patients and only 11% of these could have
re-resection for curative intent. Recurrence was found in asymptomatic
patients by a scheduled follow-up procedure in 26% of all recurrences.
Three-year survival was 31% in these patients versus 13% for all
patients. These authors used this data to justify an intensive follow-up
schedule. A similar analysis in 563 patients with curative resection who
were followed for 10 years with regular clinic visits and chest
radiography found that only 3.8% of patients were able to undergo a
second curative resection based on this program. The calculated cost per
life-year gained was approximately \$75,000. This cost was far above
other large-scale surveillance programs in their country, and the
intensity and duration of follow-up were reduced.

With respect to second primary lung cancers (SPLC) alone, one may
identify highly selected subsets of patients who can benefit from
aggressive follow-up. One study analyzed the records of the National
Cancer Institute (NCI) Intergroup trial NCI#I91-0001 examining the
effectiveness of isoretinoin A for chemoprevention of second primary
tumors after complete resection of pathologic stage I NSCLC. All of
these patients had rigorous follow-up designed to detect SPLCs. Among
the 569 patients randomized to the placebo arm, second primary tumors of
all kinds were found in 88 (15%) patients. Only 49 of these patients had
SPLC (incidence of 1.99/100 patient-years). Despite semi-annual
follow-up with chest radiographs, 12 (24%) patients had metastatic
disease at the time of diagnosis and only 31 (63%) patients underwent
surgery. Median survival was 4.1 years for those patients who had
surgery and 1.4 years for those who did not and this difference was
highly significant. On the whole, these data support regular clinical
exams and chest radiographs for post-resection follow-up.

The value of chest spiral CT has been evaluated as a screening tool in
high-risk smokers, but it has a high false positive rate and is not
sensitive for detecting endobronchial disease or preinvasive disease. It
is attractive to speculate that applying this technology to follow-up of
resected lung cancer patients might identify recurrences earlier,
resulting in more curative re-resections. There is no doubt this is
being done to some extent in daily practice. No controlled trials on use
of low-dose spiral CT in follow-up of lung cancer patients have been
done. Smaller experiences confirm the usefulness of this modality in
confirming recurrence when compared to chest radiography, but the impact
on survival is unknown. For now, it may be reasonable to replace a
follow-up chest radiograph with chest CT scans in high-risk patients
after resection.

If the case for avoiding aggressive follow-up in resected patients is
controversial, then it is surely less so in patients with unresectable
NSCLC treated with chemotherapy, chemoradiotherapy, or other combined
modality approaches. These patients tend to fail soon after therapy with
symptomatic metastases, and most imaging is focused on restaging the
patient for salvage therapy. Routine post-therapy imaging of
asymptomatic patients outside of clinical trials cannot be recommended
until more effective salvage regimens are developed.

New imaging technologies are being investigated, but no controlled
clinical trials establish their use in routine follow-up. PET has been
evaluated in follow-up of NSCLC primarily in unresected patients. It is
felt to be less sensitive for evaluating metastatic or recurrent cancer
than it is in initial staging. It is probably more accurate than CT in
distinguishing tumor from fibrotic scar or pneumonitis in NSCLC
patients. One study demonstrated a significantly improved survival in
patients with a negative PET scan after first line treatment. The
combination of PET/CT improves the diagnostic accuracy over that of
either test alone. Other modalities such as 99mTC-tetrofosmin
scintigraphy, Tc99m-sestamibi (Tc99m MIBI) and thallium-201 chloride
single photon emission computed tomography (SPECT), and whole-body MRI
have been investigated but have no proven clinical usefulness in routine
follow-up.

Since the previous edition of the American College of Radiology
guidelines, the American Society of Clinical Oncology has published
guidelines for treatment of unresectable NSCLC. They recommended
maintaining regular physical exams but did not advocate regular imaging
in asymptomatic patients. They acknowledged the investigational nature
of low-dose spiral chest CT as a routine follow-up study. Many of the
interventions described above, including fiberoptic bronchoscopy, sputum
cytologies, tumor markers, and more established imaging studies,
continue to have value in follow-up of symptomatic patients or in
clinical trials. These recommendations acknowledge the disappointing
efficacy of salvage regimens after first therapy despite early diagnosis
of recurrence, as well as, their additional cost to the patient. Under
the circumstances, similar recommendations from this report are
justifiable.

**Abbreviations**

-   CT, computed tomography

-   KPS, Karnofsky performance score

-   MRI, magnetic resonance imaging

-   NSE, neuron specific enolase

-   NUC, nuclear medicine

-   PET, positron emission tomography

-   TPA, tissue polypeptide antigen

-   US, ultrasound

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for the follow-up
of non-small cell lung cancer

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Thomas WW Jr, Komaki RU, Gewanter RM, Gopal RS, Movas B, Rosenzweig KE,
Weisenberger TH, Wolkov HB, Kaiser LR, Mauch PM, Schiller JH, Expert
Panel on Radiation Oncology\--Lung Work Group. Follow-up of non-small
cell lung cancer. Reston (VA): American College of Radiology (ACR);
2005. 6 p. \[23 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1996 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Radiation
Oncology\--Lung Work Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: William W. Thoms, Jr, MD; Ritsuko U. Komaki, MD;
Richard M. Gewanter, MD; Ramesh S. Gopal, MD; Benjamin Movas, MD;
Kenneth E. Rosenzweig, MD; Thomas H. Weisenburger, MD; Harvey B. Wolkov,
MD; Larry R. Kaiser, MD; Peter M. Mauch, MD; Joan H. Schiller, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previously published version: Sause WT, Byhardt RW, Curran
WJ Jr, Fuller D, Graham MV, Ko B, Komaki R, Weisenburger TH, Kaiser LR,
Leibel SA, Brown RC. Follow-up of non-small cell lung cancer. American
College of Radiology. ACR Appropriateness Criteria. Radiology. 2000
Jun;215 Suppl:1363-72.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonRadiationOncologyLungWorkGroup/FollowUpofNonSmallCellLungCancerDoc1.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on February 14, 2006.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/10/2008