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## Complete Summary

#### GUIDELINE TITLE

Bronchial intraepithelial neoplasia/early central airways lung cancer:
ACCP evidence-based clinical practice guidelines. (2nd Edition)

#### BIBLIOGRAPHIC SOURCE(S)

Kennedy TC, McWilliams A, Edell E, Sutedja T, Downie G, Yung R, Gazdar
A, Mathur PN, American College of Chest Physicians. Bronchial
intraepithelial neoplasia/early central airways lung cancer: ACCP
evidence-based clinical practice guidelines (2nd edition). Chest 2007
Sep;132(3 Suppl):221S-33S. \[107 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17873170)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Mathur PN, Edell E, Sutedja
T, Vergnon JM. Treatment of early stage non-small cell lung cancer.
Chest 2003 Jan;123(1 Suppl):176S-80S.

### COMPLETE SUMMARY CONTENT

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

### SCOPE

#### DISEASE/CONDITION(S)

Early stage non-small cell lung cancer

#### GUIDELINE CATEGORY

Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Oncology\
Pulmonary Medicine\
Thoracic Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Nurses\
Patients\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians\
Social Workers

#### GUIDELINE OBJECTIVE(S)

To provide an evidence-based approach for the localization and
management of intraepithelial and microinvasive non-small cell lung
cancer in the central airways

#### TARGET POPULATION

Patients with early stage non-small cell lung cancer (NSCLC)

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Photodynamic therapy (PDT)

2.  Electrocautery

3.  Cryotherapy

4.  Brachytherapy

5.  Neodymium-yttrium aluminum garnet (Nd-YAG) laser therapy (considered
    but not recommended)

#### MAJOR OUTCOMES CONSIDERED

-   Response to treatment (complete, partial, or no response)

-   Recurrence rate

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

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

**Overview**

The American College of Chest Physicians (ACCP) chose the Duke
University Center for Clinical Health Policy Research to perform formal
systematic reviews of the current evidence in the five new non-small
cell lung cancer (NSCLC) topic areas, as well as to provide a search for
the existing guidelines, systematic reviews, and meta-analyses in all of
the topics areas. In addition, the Agency for Healthcare Quality and
Research) AHRQ agreed to fund the BlueCross BlueShield Association
Technology Evaluation Center to perform the formal systematic review of
literature on small cell lung cancer (SCLC). The Health Outcomes
Research Group of the Department of Epidemiology and Biostatistics at
Memorial Sloan-Kettering Cancer Center conducted a full-scale review of
the literature since the first set of guidelines in the area of
screening for lung cancer to assist that particular writing group.

The formal systematic reviews of the five new topic areas were guided by
the appropriate chapter editors and their writing committees, in concert
with the Executive Committee of the panel.

The two EPC research teams conducted a variety of systematic
computerized bibliographic database searches including the following:
(1) a search for systematic reviews, guidelines, and meta-analyses
published since the last ACCP lung cancer guideline (MEDLINE, The
Cochrane Library, National Guidelines Clearinghouse); (2) targeted
searches for reviews in each of five selected treatment sections
(solitary pulmonary nodules, stage I and II, stage IIIA, stage IIIB,
stage IV); these searches, run in OVID version of MEDLINE, were
performed in July and August 2005 and were limited to publication years
since 1995, English language, and human subjects; and (3) searches
related to SCLC are described in the evidence chapter on SCLC. Search
terms included the medical subject heading terms lung neoplasms
(exploded) and bronchial neoplasms for the lung cancer concept. Each
topic search utilized key words specific to the key questions of
interest (complete search strategies are available on request from the
authors).

**Strategy Specific for Bronchial Intraepithelial Neoplasia/Early
Central Airways Lung Cancer**

To update previous recommendations on bronchial intraepithelial
neoplasia/early central airways lung cancer, guidelines on lung cancer
diagnosis and management were identified by a systematic review of the
literature (see the \"Availability of Companion Documents\" field in
this summary for \"Methodology for Lung Cancer Evidence Review and
Guidelines Development\"). Supplemental material appropriate to this
topic was obtained by literature search of a computerized database
(MEDLINE) in the English language from January 1966 to January 2006, and
review of the Thoracic Oncology NetWork reference lists of relevant
articles. The search words that were used were as follows: \"carcinoma
*in situ*\" (CIS), \"angiogenic squamous dysplasia\" (ASD),
\"radiographically occult lung cancer,\" \"neodymium
yttrium-aluminum-garnet,\" \"photodynamic therapy,\" \"electrocautery,\"
\"cryotherapy,\" \"non-small cell lung cancer\" (NSCLC), \"light-induced
fluorescence endoscopy,\" \"white light bronchoscopy,\" (WLB)
\"autofluorescence bronchoscopy,\" (AFB) \"flexible videobronchoscopy\"
(FVB), and \"narrow band imaging\" (NBI).

For the purposes of this guideline, the reviewed literature was limited
to diagnostic and treatment approaches to early stage lung cancer. The
definition of an early stage cancer is a roentgenographically occult
squamous cell carcinoma (SqCC) that is \< 2 cm in surface area, appears
superficial endoscopically, has clearly visible margins, and
demonstrates no invasion beyond the bronchial cartilage assessed either
by histopathology or by available imaging including high-resolution CT
or endobronchial ultrasound. Although there is an extensive literature
on the detection and treatment of early stage lung cancer, the reported
studies consist of small to moderate-size case series. Clinical outcomes
in these studies were defined as response to treatment and included
complete, partial, or no response. Complete response was defined as no
evidence of disease visually as well as on histology and cytology
examination. Some studies also included time to tumor recurrence.
Relative sensitivity is commonly used in these reports to express the
additional value of AFB over WLB when, as in most reports, WLB was
performed before AFB by the same observer and the actual prevalence of
lesions was unknown. Relative sensitivity is defined as the ratio of the
sensitivity of WLB alone or WLB combined with AFB divided by the
sensitivity of WLB alone.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

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

Expert Consensus\
Weighting According to a Rating Scheme (Scheme Given)

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

**High** - Randomized controlled trials (RCTs) without important
limitations or overwhelming evidence from observational studies\*

**Moderate** - RCTs with important limitations (inconsistent results,
methodologic flaws, indirect, or imprecise) or exceptionally strong
evidence from observational studies\*

**Low or very low** - Observational studies or case series

\*Although the determination of magnitude of the effect based on
observational studies is often a matter of judgment, the guideline
developers offer the following suggested rule to assist this decision: a
large effect would be a relative risk \> 2 (risk ratio \< 0.5) \[which
would justify moving from weak to moderate\], and a very large effect is
a relative risk \> 5 (risk ratio \< 0.2) \[which would justify moving
from weak to strong\]. There is some theoretical justification in the
statistical literature for these thresholds (the magnitude of effect
that is unlikely or very unlikely to be due to residual confounding
after adjusted analysis). However, once the decision is made, authors
should be explicit in justifying their decisions.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

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

Quality of evidence is scored in three categories with high-quality
evidence obtained from randomized controlled trials (RCTs) without
important methodologic limitations based on the study design, the
consistency of the results, and the directness of the evidence. In
extraordinary circumstances, significant and consistent evidence from
observational studies could also be ranked as high quality. RCTs with
important methodologic limitations or flaws, inconsistent results, or
indirect or imprecise results would be scored as medium quality, as well
as exceptionally strong evidence from observational studies. Other
observational studies or case-series data would fall into the low
quality of evidence category. It is the interface of the quality of the
evidence and the balance of benefits to harms or burdens that determines
the strength of the recommendation, with a 1A recommendation being the
strongest and 2C the weakest.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus\
Informal Consensus

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

Writing committees studied the evidence and summary tables or reviewed
the literature for their assigned topics, developing their arguments for
the recommendations and suggested grading of those recommendations that
were put forth for early drafts. The Executive Committee of the panel,
composed of the Chair, Vice-Chair, methodologist, and both project
managers, reviewed drafts of each chapter of the manuscript during the
writing process. Sections that were determined to be potentially
overlapping were shared among the appropriate chapter editors, and
conference calls were organized to coordinate the placement of these
sections and to confirm that there would be no conflicting information
or recommendations.

A conference of the panel was convened in July 2006, prior to which time
all panelists, including representatives from the invited organizations,
were requested to review the complete manuscript and identify
recommendations for which the proposal, wording, or grading were
determined to be controversial or could be interpreted as controversial
by others, incorrectly evolved from the evidence, disagreement existed
with regard to the proposal or the grading, or required full panel
discussion and further review for any reason. When the panelists who
were present were not in unanimous agreement with the proposed
recommendations or the grading of the recommendations, informal group
consensus techniques were employed. After the meeting, a series of
conference calls were convened to finish the discussions and finalize
the recommendations. There were a few chapters for which there was
insufficient time for full dialogue during the meeting; in the interest
of ensuring that the recommendations followed the evidence, the
conference calls were necessary. This process ensured the \"buy-in\" of
the panelists and was deemed to be a worthwhile effort.

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

**Grade of Recommendations Scale**

  -----------------------------------------------------------------------
  **Grade**                           **Recommendation**
  ----------------------------------- -----------------------------------
  1A                                  Strong

  1B                                  Strong

  1C                                  Strong

  2A                                  Weak

  2B                                  Weak

  2C                                  Weak
  -----------------------------------------------------------------------

**Relationship of Strength of the Supporting Evidence to the Balance of
Benefits to Risks and Burdens**

  ---------------------------------------------------------------------------------
  **Balance of                                                      
  Benefits to                                                       
  Risks and                                                         
  Burdens**                                                         
  -------------- ----------------- ----------------- -------------- ---------------
  **Quality of   **Benefits        **Risks/Burdens   **Evenly       **Uncertain**
  Evidence**     Outweigh          Outweigh          Balanced**     
                 Risks/Burdens**   Benefits**                       

  **High**       1A                1A                2A              

  **Moderate**   1B                1B                2B              

  **Low or very  1C                1C                2C             2C
  low**                                                             
  ---------------------------------------------------------------------------------

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Following final chapter revisions and incorporation of these ultimate
recommendations and grading, a concluding review was conducted by the
guideline panel Executive Committee. The guidelines were then submitted
for review and approval to the American College of Chest Physicians
Health and Science Policy Committee (ACCP HSP) Committee, as well as the
Thoracic Oncology Network of the college.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions for the strength of evidence and recommendation grades
(1A-2C) follow the recommendations.

1.  For patients with severe dysplasia, carcinoma *in situ* (CIS) or
    carcinoma in sputum cytology but with chest imaging studies showing
    no localizing abnormality, standard white light bronchoscopy (WLB)
    is recommended. Autofluorescence bronchoscopy (AFB) should be used
    when available. **Grade of recommendation, 1B**

2.  For patients being considered for curative endobronchial therapy to
    treat CIS in centers where it is available, AFB may be considered to
    guide therapy. **Grade of recommendation, 2C**

3.  For patients with known severe dysplasia or CIS in the central
    airways, standard WLB is recommended at periodic intervals (3 to 6
    months) for follow-up. AFB should be used when available. **Grade of
    recommendation, 2C**

4.  For patients with squamous cell carcinoma (SqCC) who are not
    surgical candidates, photodynamic therapy (PDT), electrocautery,
    cryotherapy, and brachytherapy are recommended as treatment options.
    Use of Neodymium-yttrium aluminum garnet (Nd-YAG) laser therapy is
    not recommended because of the risk of perforation. **Grade of
    recommendation, 1C**

**[Definitions]{.underline}**:

**Quality of Evidence Scale**

**High** - Randomized controlled trials (RCTs) without important
limitations or overwhelming evidence from observational studies\*

**Moderate** - RCTs with important limitations (inconsistent results,
methodologic flaws, indirect, or imprecise) or exceptionally strong
evidence from observational studies\*

**Low or very low** - Observational studies or case series

\*Although the determination of magnitude of the effect based on
observational studies is often a matter of judgment, the guideline
developers offer the following suggested rule to assist this decision: a
large effect would be a relative risk \> 2 (risk ratio \< 0.5) \[which
would justify moving from weak to moderate\], and a very large effect is
a relative risk \> 5 (risk ratio \< 0.2) \[which would justify moving
from weak to strong\]. There is some theoretical justification in the
statistical literature for these thresholds (the magnitude of effect
that is unlikely or very unlikely to be due to residual confounding
after adjusted analysis). However, once the decision is made, authors
should be explicit in justifying their decisions.

**Grade of Recommendations Scale**

  -----------------------------------------------------------------------
  **Grade**                           **Recommendation**
  ----------------------------------- -----------------------------------
  1A                                  Strong

  1B                                  Strong

  1C                                  Strong

  2A                                  Weak

  2B                                  Weak

  2C                                  Weak
  -----------------------------------------------------------------------

**Relationship of Strength of the Supporting Evidence to the Balance of
Benefits to Risks and Burdens**

  ---------------------------------------------------------------------------------
  **Balance of                                                      
  Benefits to                                                       
  Risks and                                                         
  Burdens**                                                         
  -------------- ----------------- ----------------- -------------- ---------------
  **Quality of   **Benefits        **Risks/Burdens   **Evenly       **Uncertain**
  Evidence**     Outweigh          Outweigh          Balanced**     
                 Risks/Burdens**   Benefits**                       

  **High**       1A                1A                2A              

  **Moderate**   1B                1B                2B              

  **Low or very  1C                1C                2C             2C
  low**                                                             
  ---------------------------------------------------------------------------------

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate localization and management of intraepithelial and
microinvasive non-small cell lung cancer in the central airways

#### POTENTIAL HARMS

Not stated

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The publication of the *Diagnosis and Management of Lung Cancer: ACCP
Evidence-Based Clinical Practice Guidelines; Second Edition* in *CHEST*
is the first of two dissemination vehicles. The circulation of the
journal is 23,000 subscribers and libraries, including six translations
and distribution to 107 countries. All subscribers received a copy of
this full-text guideline. The American College of Chest Physicians
(ACCP) Clinical Resource on Lung Cancer is composed of a printed
publication and an accompanying CD-ROM, containing a quick reference
guide for physicians and other health-care providers, patient-targeted
educational materials, and a set of slides for use in educational or
clinical contexts. In addition, the recommendations and grading are
personal digital assistant downloadable from the clinical resource. This
product is available for purchase from the ACCP. The patient education
materials are accessible free of charge on
[www.chestnet.org](http://www.chestnet.org/patients/guides).

The implementation and translation of evidence-based clinical practice
guidelines facilitates knowledge uptake, critical for practice change,
and should ultimately lead to better patient-focused care. The HSP
Subcommittee on Implementation has proposed to collaborate with the
Governors, Thoracic Oncology Network, and other groups within the ACCP
to disseminate and implement the guidelines in their local communities.
Residency and specialty training programs are encouraged to use the
guidelines in journal clubs and grand rounds. Other organizations that
were invited to send representatives to the final conference and review
the proposed drafts were also requested to endorse the guidelines and
market them to their membership through their own communication
channels.

#### IMPLEMENTATION TOOLS

Patient Resources\
Resources

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

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Kennedy TC, McWilliams A, Edell E, Sutedja T, Downie G, Yung R, Gazdar
A, Mathur PN, American College of Chest Physicians. Bronchial
intraepithelial neoplasia/early central airways lung cancer: ACCP
evidence-based clinical practice guidelines (2nd edition). Chest 2007
Sep;132(3 Suppl):221S-33S. \[107 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17873170)

#### ADAPTATION

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

#### DATE RELEASED

2003 Jan (revised 2007 Sep)

#### GUIDELINE DEVELOPER(S)

American College of Chest Physicians - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Chest Physicians

#### GUIDELINE COMMITTEE

American College of Chest Physicians (ACCP) Expert Panel on Lung Cancer
Guidelines

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: Timothy C. Kennedy, MD, FCCP; Annette McWilliams, MD,
FCCP; Eric Edell, MD, FCCP; Tom Sutedja, MD, PhD FCCP; Gordon Downie,
MD, PhD, FCCP; Rex Yung, MD, FCCP; Adi Gazdar, MD; Praveen N. Mathur,
MBBS, FCCP

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Funding for both the evidence review and guideline development was
supported by educational grants from AstraZeneca LP, Bristol-Myers
Squibb Company, Eli Lilly and Company, Genentech, and Sanofi-Aventis.
Representatives from these companies were neither granted the right of
review, nor were they allowed participation in any portion of the
guideline development process. This precluded participation in either
conference calls or conferences. No panel members or ACCP reviewers were
paid any honoraria for their participation in the development and review
of these guidelines.

The ACCP approach to the issue of potential or perceived conflicts of
interest established clear firewalls to ensure that the guideline
development process was not influenced by industry sources. This policy
is published on the ACCP Web site at
[www.chestnet.org](http://www.chestnet.org/). All conflicts of interest
within the preceding 5 years were required to be disclosed by all
panelists, including those who did not have writing responsibilities, at
all face-to-face meetings, the final conference, and prior to submission
for publication. The most recent of these conflict of interests are
documented in this guideline Supplement. Furthermore, the panel was
instructed in this matter, verbally and in writing, prior to the
deliberations of the final conference. Any disclosed memberships on
speaker\'s bureaus, consultant fees, grants and other research monies,
and any fiduciary responsibilities to industry were provided to the full
panel in writing at the beginning of the conference and at submission
for publication.

#### ENDORSER(S)

American Association for Bronchology - Disease Specific Society\
American Association for Thoracic Surgery - Medical Specialty Society\
American College of Surgeons - Medical Specialty Society\
American Society for Therapeutic Radiology and Oncology\
Asian Pacific Society of Respirology - Disease Specific Society\
Oncology Nursing Society - Professional Association\
Society of Thoracic Surgeons - Medical Specialty Society\
World Association of Bronchology - Disease Specific Society

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Mathur PN, Edell E, Sutedja
T, Vergnon JM. Treatment of early stage non-small cell lung cancer.
Chest 2003 Jan;123(1 Suppl):176S-80S.

#### GUIDELINE AVAILABILITY

Electronic copies: Available to subscribers of [Chest - The
Cardiopulmonary and Critical Care
Journal](http://www.chestjournal.org/content/vol132/3_suppl/).

Print copies: Available from the American College of Chest Physicians,
Products and Registration Division, 3300 Dundee Road, Northbrook IL
60062-2348.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

Executive Summary:

-   Alberts MW. Diagnosis and management of lung cancer executive
    summary. Chest 2007 Sep;132(3 Suppl):1S-19.

Background Articles:

-   Alberts WM. Introduction: diagnosis and management of lung cancer.
    Chest 2007 Sep;132(3 Suppl):20S-22.

-   McCrory DC, Lewis SZ, Heitzer J, Colice GL, Alberts WM. Methodology
    for lung cancer evidence review and guideline development. Chest
    2007 Sep;132(3 Suppl):23S-28.

-   Alberg AJ, Ford JG, Samet JM. Epidemiology of lung cancer. Chest
    2007 Sep;132(3 Suppl):29S-55.

Electronic copies: Available to subscribers of [Chest - The
Cardiopulmonary and Critical Care
Journal](http://www.chestjournal.org/content/vol132/3_suppl/).

Print copies: Available from the American College of Chest Physicians,
Products and Registration Division, 3300 Dundee Road, Northbrook IL
60062-2348.

The following is also available:

-   ACCP clinical resources: Diagnosis and management of lung cancer:
    ACCP evidence-based clinical practice guidelines (2nd edition).

Available from the [American College of Chest Physicians Web
site](https://accp.chestnet.org/storeWA/StoreAction.do?method=home).

#### PATIENT RESOURCES

The following are available:

-   Lung cancer guides: lung cancer\...am I at risk? Patient education
    guide. Northbrook (IL): American College of Chest Physicians, 2004.
    12 p.

-   Lung cancer guides: What if I have a spot on my lung? Do I have
    cancer? Patient education guide. Northbrook (IL): American College
    of Chest Physicians, 2004. 16 p.

-   Lung cancer guides: living with lung cancer. Patient education
    guide. Northbrook (IL): American College of Chest Physicians, 2004.
    12 p.

-   Lung cancer guides: advanced lung cancer: issues to consider.
    Patient education guide. Northbrook (IL): American College of Chest
    Physicians, 2004. 12 p.

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Chest Physicians (ACCP) Web
site](http://chestnet.org/patients/guides/).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on July 22, 2003. The information
was verified by the guideline developer on August 18, 2003. This NGC
summary was updated by ECRI Institute on November 12, 2007. The updated
information was verified by the guideline developer on December 21,
2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008