![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

The role of thoracic radiotherapy as an adjunct to standard chemotherapy
in limited-stage small cell lung cancer.

#### BIBLIOGRAPHIC SOURCE(S)

Lung Cancer Diseases Site Group. The role of thoracic radiotherapy as an
adjunct to standard chemotherapy in limited-stage small cell lung cancer
\[full report\]. Toronto (ON): Cancer Care Ontario (CCO); 2003 Jan
\[online update\]. 20 p. (Practice guideline; no. 7-13-3). \[30
references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

The FULL REPORT, initially the full original Guideline or Evidence
Summary, over time will expand to contain new information emerging from
their reviewing and updating activities.

Please visit the [Cancer Care Ontario Web
site](http://www.cancercare.on.ca/pdf/full7_13_3.pdf) for details on any
new evidence that has emerged and implications to the guidelines.

### 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)

Limited-stage small cell lung cancer

#### GUIDELINE CATEGORY

Assessment of Therapeutic Effectiveness\
Management\
Treatment

#### CLINICAL SPECIALTY

Oncology\
Radiation Oncology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To determine if there is a role for thoracic radiotherapy as an adjunct
to standard chemotherapy in limited-stage small cell lung cancer (SCLC)

#### TARGET POPULATION

Adult patients with limited-stage small cell lung cancer

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Chemotherapy, including cisplatin, etoposide, cyclophosphamide,
    doxorubicin, vincristine, and vindesine, alone

2.  Combined chemotherapy plus thoracic radiotherapy, including
    sequential, alternating, concurrent, early or late thoracic
    radiotherapy; high-dose or low-dose thoracic radiotherapy; or
    hyperfractionated radiotherapy (Note: hyperfractionated therapy is
    considered but not recommended)

#### MAJOR OUTCOMES CONSIDERED

-   Survival (median, overall two-year, overall five-year, and
    progression-free survival)

-   Local control

-   Complete response rate

-   Treatment toxicity

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

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

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

**1999 Guideline**

A MEDLINE search was initially conducted from 1990 to July 1998 and
updated to March 1999, using the terms \[lung neoplasms AND carcinoma,
small cell AND thoracic (tw)\]. A CANCERLIT search was conducted for
1995 to July 1998 and updated to February 1999, using the same
terminology. The Physician Data Query File (PDQ; U.S. National Cancer
Institute) was also searched for clinical trials using the terms \[lung
cancer, small cell AND radiation therapy\] as was the Cochrane Library
(1998, Issue 2).

**2003 Update**

The original literature search has been updated using MEDLINE and
CANCERLIT (through December and October 2002 respectively), and the
Cochrane Library (Issue 4, 2002). The proceedings of the annual meeting
of the American Society of Clinical Oncology (1998-2002) were also
searched.

*Inclusion Criteria*

Articles were selected for inclusion in this systematic review of the
evidence if they met the following criterion:

1.  Meta-analyses or randomized controlled trials that compared
    chemotherapy plus radiotherapy with chemotherapy alone, early with
    late thoracic radiotherapy (TRT), sequential with concurrent TRT, or
    different doses of TRT in patients with limited-stage small cell
    lung cancer.

**Note**: Limited-stage small cell lung cancer is defined as a tumour
confined to the hemithorax of origin, the mediastinum and the
supraclavicular nodes, which can be encompassed within a \"tolerable\"
radiotherapy port (Physician Data Query database, National Cancer
Institute). Early radiation is generally defined as radiation therapy
that is given within the first several cycles of chemotherapy, whereas
late radiation therapy is radiotherapy started with the last scheduled
course of chemotherapy or after the total course of chemotherapy is
completed.)

#### NUMBER OF SOURCE DOCUMENTS

**1999 Guideline**

2 published meta-analyses

9 randomized controlled trials

**2003 Update**

7 randomized controlled trials

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

Expert Consensus (Committee)

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

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Meta-Analysis of Randomized Controlled Trials\
Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

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

**1999 Guideline**

The Cancer Care Ontario Practice Guidelines Initiative\'s (CCOPGI)
Resource Group pooled five-year survival data from four randomized
controlled trials comparing early to late thoracic radiotherapy (TRT) to
obtain a more precise estimate of the effect of TRT given early or late
in the chemotherapy regimen. The Meta-Analyst^0.988^ program provided by
Dr. J. Lau, Tufts New England Medical Centre, was used to perform this
analysis. Where the data were analyzed by the Cancer Care Ontario
Practice Guidelines Initiative, odds ratios and 95% confidence intervals
were calculated using a random effects model. Results are expressed such
that a mortality odds ratio less than 1.0 favours early TRT. In
contrast, the data from one published report of a meta-analysis was
reported as the odds ratio of surviving, and in this case, a ratio
greater than 1.0 favours early TRT.

**2003 Update**

No further evidence synthesis has been performed.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

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

**1999 Guideline**

An initial draft of this guideline was formulated by a group member; the
draft was subsequently discussed and moulded into the final form in
response to both group discussions and practitioner feedback.

Combination chemotherapy has become accepted as part of the standard
treatment for limited-stage small cell lung cancer. The Lung Cancer
Disease Site Group (DSG) is in the process of developing a practice
guideline on optimal chemotherapy for the initial management of
limited-stage small cell lung cancer, which will be issued as Practice
Guideline Report #7-13-1 titled, \"[The role of combination chemotherapy
in the initial management of limited disease small cell lung
cancer](http://www.cancercare.on.ca/pdf/pebc7-13-1s.pdf).\"

One concern raised during practitioner feedback was the practical
feasibility of instituting radiotherapy early in the treatment course
(for example, with the second course of chemotherapy) given the limited
and strained resources faced by many cancer centres in Ontario. Despite
this reality, the guidelines process has been instituted in order to
recommend optimal current therapy towards which the medical community
should strive for the benefit of the patient population served. Because
of the magnitude of the benefit observed, even some heavily strained
radiotherapy treatment centres have instituted early thoracic
radiotherapy through effective communication between medical and
radiation oncologists and teamwork with simulation and treatment staff.

Another relevant concern related to whether treatment volumes should be
based upon the pre or post chemotherapy tumour volumes. Given the
recommendation for early thoracic irradiation (that is, with either the
first or second course of chemotherapy), the impact of this question is
significantly lessened and logic therefore dictates that radiation
portals will be based upon the pre-treatment tumour volume. This is
particularly highlighted by the practical situation that simulation
would be performed during or conceivably even before the first course of
chemotherapy in preparation for commencement of early irradiation. There
is one randomized trial of 191 patients which addressed the question of
treatment volume. In this study, intrathoracic recurrence rates were not
statistically different between radiotherapy based upon preinduction
versus postinduction chemotherapy.

There was considerable discussion within the Lung Cancer DSG about the
appropriateness of recommending hyperfractionated radiotherapy to
patients with limited small cell lung cancer (SCLC) on the basis of a
single study, particularly as a second study, not yet fully reported,
has not shown a similar survival advantage. In addition, the control arm
of the Turrisi trial used a dose of radiation (45 Gy in 25 fractions)
which is biologically less intense than the dose generally employed by
Canadian radiation oncologists (40 Gy in 15 fractions). Furthermore, the
results achieved with twice daily radiotherapy appear quite similar to
those of the best arms of the Canadian trial (BR6) which showed that
early radiotherapy is superior to late radiotherapy when combined with
alternating cyclophosphamide, adriamycin, vincristine, cisplatin
(CAV-EP) chemotherapy. Ideally, a randomized trial should compare early
twice daily radiotherapy to early radiotherapy as administered in the
Canadian trial (40 Gy in 15 daily fractions).

**2003 Update**

The Lung Cancer DSG continues to believe that hyperfractionated
radiotherapy should not be used outside of a clinical trial for limited
stage small cell lung cancer.

The new data found through the updating process provides conflicting
evidence regarding the timing of radiotherapy. Although evidence
regarding the use of concurrent chemoradiotherapy is conflicting, the
new data from a trial evaluating concurrent versus alternating
radiotherapy underscores the importance of the specific chemotherapy
drugs used with the radiotherapy. Lebeau et al had more frequent and
more serious lung toxicity with concurrent chemoradiotherapy compared
with alternating radiotherapy. In this trial, the initial chemotherapy
regimen included doxorubicin, which probably contributed to the high
rate of serious pulmonary toxicity and higher mortality rate in the
concurrently treated arm of the study. This observation does not negate
the concept of concurrent chemo-radiotherapy, but rather highlights the
need to identify chemotherapy regimens that can be safely combined with
radiotherapy. There is substantial experience with the combination of
etoposide-cisplatin in combination with radiotherapy and this should be
the standard outside of a clinical trial.

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

Not applicable

#### COST ANALYSIS

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

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Practitioner feedback was obtained through a mailed survey\* of 64
medical and radiation oncologists in Ontario. The survey consisted of
items evaluating the methods, results, and interpretive summary used to
inform the draft recommendations and whether the draft recommendations
should be approved as a practice guideline. Written comments were
invited. Follow-up reminders were sent at two weeks (post card) and four
weeks (complete package mailed again). The results of the survey were
reviewed by the Lung Cancer Disease Site Group.

The practice guideline recommendations reflect the integration of the
draft recommendations with feedback obtained from the External Review
process.

Final approval of the original guideline document was obtained from the
Practice Guidelines Coordinating Committee.

\*Practitioner feedback was obtained using two versions of a mailed
survey. One version of the questionnaire, the version traditionally used
by the Cancer Care Ontario Practice Guidelines Initiative, contained
nine questions. The second version, an experimental version, contained
21 questions. Practitioners eligible to participate in the survey were
randomly assigned one of the two questionnaires, with the result that 33
practitioners received the experimental version and 31 practitioners,
the traditional version. The two questionnaires had six questions in
common; data in Table 4 of the original guideline represent practitioner
responses to the six common questions, pooled across the versions of the
questionnaires.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

-   In patients with limited-stage small cell lung cancer, the addition
    of thoracic radiotherapy to standard combination chemotherapy
    improves both local control and overall survival and should be
    incorporated into a comprehensive treatment plan of combined
    modality therapy for limited-stage small cell lung cancer.

-   The data from randomized trials suggest that higher doses of
    thoracic radiotherapy produce better local control and
    progression-free survival. Although the optimal dose has not yet
    been established, those trials that demonstrate a superior survival
    outcome from radiotherapy and chemotherapy over chemotherapy alone
    have generally used a total dose of at least 40 Gy in 15 fractions
    over three weeks (or a biologically equivalent dose). The radiation
    oncologist must assess the appropriateness and safety of this
    recommendation for individual patients, taking into consideration
    tumour field size and location, pulmonary function tests and other
    clinical factors. These factors are important as the improvement in
    overall survival occurs with an increased risk of death due to the
    toxicity of combined modality therapy.

-   There is conflicting evidence as to the optimal timing of thoracic
    radiotherapy in relation to the course of chemotherapy (early or
    late administration of thoracic radiotherapy). The evidence is also
    conflicting regarding the issue of concurrent versus sequential
    administration of chemotherapy with radiotherapy.

-   Based on currently available data, hyperfractionated thoracic
    radiotherapy is NOT recommended for limited-stage small cell lung
    cancer outside of a clinical trial.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

**1999 Guideline**

Two published meta-analyses comparing chemotherapy plus thoracic
radiotherapy (TRT) with chemotherapy alone were eligible for review. The
first meta-analysis analyzed published results from 11 trials and the
second examined individual patient data from 13 trials; there was
substantial overlap between the trials analyzed in the two
meta-analyses. Nine randomized controlled trials were also eligible for
review (six were fully published). Six of the nine randomized controlled
trials investigated the timing of TRT delivery. The Cancer Care Ontario
Practice Guidelines Initiative\'s (CCOPGI\'s) Resource Group pooled
published data from four randomized controlled trials examining early
versus late TRT delivery. One of the nine randomized controlled trials
analyzed optimal dosage of TRT delivered in conjunction with
chemotherapy, while two randomized controlled trials examined single-
versus twice-daily TRT treatment in conjunction with chemotherapy.

**2003 Update**

Seven papers identified by a literature search from October 2000 to
December 2002 were eligible for inclusion in the systematic review of
the evidence. Two of these papers led the Lung Cancer Disease Site Group
to modify its recommendations in October 2000. One paper reported a
trial that compared chemotherapy combined with either concurrent or
alternating radiotherapy. The other paper was the full report of a trial
previously published in abstract form that compared chemotherapy plus
daily radiotherapy versus chemotherapy plus twice-daily radiotherapy.
Five additional reports of randomized trials were found, one of which
included updated results for a trial included in the original guideline
report.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**The Role of Radiotherapy with Chemotherapy**

Two published meta-analyses compared chemotherapy plus thoracic
radiotherapy with chemotherapy alone. The first meta-analysis analyzed
published results from 11 trials and the second examined individual
patient data from 13 trials; there was substantial overlap between the
trials analyzed in the two meta-analyses. Both meta-analyses
demonstrated positive benefits for thoracic radiotherapy in combination
with chemotherapy versus chemotherapy alone. One meta-analysis
demonstrated an overall benefit of thoracic radiotherapy on two-year
survival \[Odds Ratio, 1.53; 95% Confidence Interval, 1.30 to 1.76;
p=0.001\] and an absolute improvement in local control of 25.3% (95%
Confidence Interval, 16.5 to 34.1). The second meta-analysis indicated a
three-year overall survival benefit of 5.4% ± 1.4% (standard deviation)
and a Relative Risk of death of 0.86 (95% Confidence Interval, 0.78 to
0.94; p=0.001) in favour of the combined modality group. One of two
randomized trials that was not included in either meta-analysis accrued
97 patients and detected a survival benefit for combined modality
treatment over chemotherapy alone. The other trial, which involved the
use of split-course radiotherapy and a second randomization to
consolidation chemotherapy, detected no significant difference in
overall survival between treatments among 386 patients, although there
was a significant advantage in two-year progression-free survival for
irradiated patients. The reliability of the results of the latter trial
is questionable since the combined treatment arm was closed early due to
toxicity.

**Radiotherapy Timing\--Concurrent versus Sequential or Alternating
Administration**

Three randomized controlled trials compared concurrent
chemo-radiotherapy with either sequential or alternating
chemo-radiotherapy. One trial demonstrated a non-significant increase in
overall survival for patients receiving thoracic radiotherapy
concurrently with chemotherapy versus sequentially following
chemotherapy (p=0.097 logrank). However, a regression analysis adjusted
for prognostic variables detected a significant survival benefit for
concurrent treatment (Hazard Ratio, 0.70; 95% Confidence Interval, 0.52
to 0.94, p=0.02). Another small trial available only in abstract form
reported no survival benefit for concurrent over sequential
administration of radiotherapy (p=0.33). One randomized controlled trial
which compared concurrent chemo-radiotherapy with chemotherapy
alternating with thoracic radiotherapy showed no significant difference
between the two treatment arms (p=0.15 logrank).

**Radiotherapy Timing\--Early versus Late Administration**

Five randomized controlled trials investigated early versus late
thoracic radiotherapy delivery. Methodologists working with the Lung
Cancer Disease Site Group conducted a meta-analysis of published data
involving 777 patients from three of the randomized controlled trials
that examined early versus late daily thoracic radiotherapy delivery.
Two of these trials administered chemotherapy concurrently with the
radiotherapy and one administered it sequentially. Results of the
meta-analysis indicated that there was no survival benefit to
administering thoracic radiotherapy early in relation to the
chemotherapy administration schedule (Odds Ratio, 1.04; 95% Confidence
Interval, 0.45 to 2.43; p=0.9), although the treatment effects detected
in the three trials were heterogeneous. Only one of these trials
obtained a significant result: the National Cancer Institute of Canada
detected a survival advantage for early, concurrent administration of
thoracic radiotherapy compared with late, concurrent administration
(5-year survival, 20% versus 11%, respectively, p=0.008 log rank). In
addition, two randomized controlled trials compared early administration
of hyperfractionated thoracic radiotherapy (concurrent with the first
course of chemotherapy) to late administration (given concurrently with
cycle three or four of chemotherapy). In one of those trials, early
administration achieved a significantly higher local control rate and an
improvement in survival that was close to statistical significance. In
the other trial, there were no differences between administration
schedules in complete response rate or survival.

**Radiotherapy Dosage**

Two randomized controlled trials examining radiotherapy dosage reported
no significant survival benefit of high dose over low dose thoracic
radiotherapy; although in one trial, there was an improvement in local
control at higher doses.

**Hyperfractionated Radiotherapy**

Hyperfractionated thoracic radiotherapy has been shown in one large,
fully published study (417 patients) to significantly increase the
long-term survival of patients with limited small cell lung cancer
(5-year survival, 26% with hyperfractionated thoracic radiotherapy
versus 16% with once daily radiotherapy, p=0.04 logrank). This was
achieved with an increased rate of short-term grade 3 esophagitis. A
second large randomized trial (262 patients) has recently been fully
published and has not detected a survival advantage for
hyperfractionated thoracic radiotherapy (3-year survival, 29% with
hyperfractionated thoracic radiotherapy versus 34% with once daily
radiotherapy, p=0.49). Grade 3 esophagitis was again significantly more
frequent in the hyperfractionated arm.

#### POTENTIAL HARMS

One meta-analysis demonstrated an increased risk of toxic death in the
combined chemotherapy-radiotherapy group compared with the chemotherapy
alone group (Odds Ratio, 2.54; 95% Confidence Interval, 1.90 to 3.18;
p\<0.01). In one trial, grade 3 and 4 thrombocytopenia was increased in
the early hyperfractionated radiotherapy group compared with late
hyperfractionated radiotherapy (p=0.062).

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Care has been taken in the preparation of the information contained in
this document. Nonetheless, any person seeking to apply or consult these
guidelines is expected to use independent medical judgment in the
context of individual clinical circumstances or seek out the supervision
of a qualified clinician. Cancer Care Ontario makes no representation or
warranties of any kind whatsoever regarding their content or use or
application and disclaims any responsibility for their application or
use in any way.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

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

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Lung Cancer Diseases Site Group. The role of thoracic radiotherapy as an
adjunct to standard chemotherapy in limited-stage small cell lung cancer
\[full report\]. Toronto (ON): Cancer Care Ontario (CCO); 2003 Jan
\[online update\]. 20 p. (Practice guideline; no. 7-13-3). \[30
references\]

#### ADAPTATION

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

#### DATE RELEASED

1999 Oct 8 (updated online 2003 Jan)

#### GUIDELINE DEVELOPER(S)

Program in Evidence-based Care - State/Local Government Agency
\[Non-U.S.\]

#### GUIDELINE DEVELOPER COMMENT

The Practice Guidelines Initiative (PGI) is the main project of the
Program in Evidence-based Care (PEBC), a Province of Ontario initiative
sponsored by Cancer Care Ontario and the Ontario Ministry of Health and
Long-Term Care.

#### SOURCE(S) OF FUNDING

Cancer Care Ontario, Ontario Ministry and Health Long-Term Care

#### GUIDELINE COMMITTEE

Lung Cancer Disease Site Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

For a current list of members, please see the [Cancer Care Ontario Web
site](http://www.cancercare.on.ca/english/toolbox/qualityguidelines/diseasesite/lung-ebs/lung-dsg/).

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Members of the Lung Cancer Disease Site Group disclosed potential
conflict of interest information.

#### GUIDELINE STATUS

This is the current release of the guideline.

The FULL REPORT, initially the full original Guideline or Evidence
Summary, over time will expand to contain new information emerging from
their reviewing and updating activities.

Please visit the [Cancer Care Ontario Web
site](http://www.cancercare.on.ca/pdf/full7_13_3.pdf) for details on any
new evidence that has emerged and implications to the guidelines.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Cancer Care Ontario Web
site](http://www.cancercare.on.ca/pdf/full7_13_3.pdf).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   The role of thoracic radiotherapy as an adjunct to standard
    chemotherapy in limited-stage small cell lung cancer. Summary.
    Toronto (ON): Cancer Care Ontario (CCO) 1999 Oct 8 (updated online
    2003 Jan)

Electronic copies: Available in Portable Document Format (PDF) from the
[Cancer Care Ontario Web
site](http://www.cancercare.on.ca/pdf/pebc7-13-3s.pdf).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on June 5, 2002. The information was
verified by the guideline developer as of July 8, 2002. This summary was
updated on August 6, 2003. The updated information was verified by the
guideline developer on September 2, 2003.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Please refer to the
[Copyright and Disclaimer
Statements](http://www.cancercare.on.ca/ontariocancernews/copyright.html)
posted at the Cancer Care Ontario Web site.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008