Systemic Therapy for Stage IV Non-Small-Cell Lung Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Systemic Therapy for Stage IV Non-Small-Cell Lung Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Stereotactic body radiation therapy for early-stage non-small cell lung cancer: Executive Summary of an ASTRO Evidence-Based Guideline. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. American Society of Clinical Oncology Clinical Practice Guideline update on chemotherapy for stage IV non-small-cell lung cancer. Treatment of stage III non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Recommendations for the Use of White Blood Cell Growth Factors: American Society of Clinical Oncology Clinical Practice Guideline Update. American Society of Clinical Oncology 2008 clinical practice guideline update: use of chemotherapy and radiation therapy protectants. Adjuvant endocrine therapy for women with hormone receptor-positive breast cancer: american society of clinical oncology clinical practice guideline focused update. Colorectal cancer surveillance: 2005 update of an American Society of Clinical Oncology practice guideline. Preoperative or postoperative therapy for resectable oesophageal cancer: an updated practice guideline. Phase III trial of two versus four additional cycles in patients who are nonprogressive after two cycles of platinum-based chemotherapy in non small-cell lung cancer. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. American Society of Clinical Oncology provisional clinical opinion: epidermal growth factor receptor (EGFR) Mutation testing for patients with advanced non-small-cell lung cancer considering first-line EGFR tyrosine kinase inhibitor therapy. ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer. Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Locally Advanced, Unresectable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline. Preoperative or postoperative therapy for stage II or III rectal cancer: an updated practice guideline. Molecular testing guideline for selection of lung cancer patients for EGFR and ALK tyrosine kinase inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. Molecular Testing Guideline for Selection of Lung Cancer Patients for EGFR and ALK Tyrosine Kinase Inhibitors: Guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association Sentinel Lymph Node Biopsy for Patients With Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Why Do Some Lung Cancer Patients Receive No Anticancer Treatment? American Society of Clinical Oncology 1998 update of recommended breast cancer surveillance guidelines. Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology. Use of epoetin in patients with cancer: evidence-based clinical practice guidelines of the American Society of Clinical Oncology and the American Society of Hematology. Treatment of stage II non-small cell lung cancer. Canadian Thoracic Society 2012 guideline update: diagnosis and management of asthma in preschoolers, children and adults. Management of Depression in Patients With Cancer: A Clinical Practice Guideline. Use of granulocyte colony-stimulating factor (G-CSF) in patients receiving myelosuppressive chemotherapy for the treatment of cancer. Provincial Systemic Treatment Disease Site Group. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline. American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. The IASLC Lung Cancer Staging Project: proposals for the revision of the N descriptors in the forthcoming seventh edition of the TNM classification for lung cancer. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) American Society of Clinical Oncology guideline for antiemetics in oncology: update 2006. The role of endoscopy in the evaluation and treatment of patients with biliary neoplasia. Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice Guideline. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Card Chemotherapy and targeted therapy for women with human epidermal growth factor receptor 2-negative (or unknown) advanced breast cancer: American Society of Clinical Oncology Clinical Practice Guideline. The Role of High-Dose Chemotherapy and Stem-Cell Transplantation in Patients with Multiple Myeloma: A Practice Guideline of the Cancer Care Ontario Practice Guidelines Initiative Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From the American College of Physicians. Clinical Utility of the Pretreatment Glasgow Prognostic Score in Patients with Advanced Inoperable Non-small Cell Lung Cancer The role of endoscopy in the management of patients with peptic ulcer disease. Ten-year analysis of the prospective multicentre Chemo-N0 trial validates American Society of Clinical Oncology (ASCO)-recommended biomarkers uPA and PAI-1 for therapy decision making in node-negative breast cancer patients. Hypofractionated Radiation Therapy for Localized Prostate Cancer: Executive Summary of an ASTRO, ASCO, and AUA Evidence-Based Guideline. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. IV. Neurostimulation therapies. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients Systemic therapy in the curative treatment of head-and-neck squamous cell cancer: Cancer Care Ontario clinical practice guideline. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Update 2013 on the acute and continuation treatment of unipolar depressive disorders Eligibility of patients with advanced non-small cell lung cancer for phase III chemotherapy trials Guidelines for radiologically guided lung biopsy Clinical practice guidelines for the care and treatment of breast cancer: 16. Locoregional post-mastectomy radiotherapy EAU guidelines on renal cell carcinoma: the 2010 update. ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices: Executive Summary--a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Pacemaker Implantation). Low ERCC1 expression correlates with prolonged survival after cisplatin plus gemcitabine chemotherapy in non-small cell lung cancer. Society for Immunotherapy of Cancer consensus statement on immunotherapy for the treatment of bladder carcinoma Society for Immunotherapy of Cancer consensus statement on immunotherapy for the treatment of bladder carcinoma. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates for 2003. Efficacy and safety of immune checkpoint inhibitors in non-small cell lung cancer Too Sick Not to Exercise: Using a 6-Week, Home-Based Exercise Intervention for Cancer-Related Fatigue Self-management for Postsurgical Non–Small Cell Lung Cancer Patients POSITIVE study: physical exercise program in non-operable lung cancer patients undergoing palliative treatment ACC/AHA guidelines for coronary angiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography) developed in collaboration with the Society for Cardiac Angiography and  Complementary therapies and integrative medicine in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Abnormal uterine bleeding in pre-menopausal women. Recommendations for implementing stereotactic radiotherapy in peripheral stage IA non-small cell lung cancer: report from the Quality Assurance Working Party of the randomised phase III ROSEL study Venous thromboembolism prophylaxis and treatment in patients with cancer: american society of clinical oncology clinical practice guideline update 2014. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer. New Response Evaluation Criteria in Solid Tumors (RECIST) guidelines for advanced non-small cell lung cancer: comparison with original RECIST and impact on assessment of tumor response to targeted therapy. An Evidence-Based Approach to the Use of Predictive Biomarkers in the Treatment of Non- Small Cell Lung Cancer (NSCLC) Consolidation docetaxel after concurrent chemoradiotherapy in stage IIIB non-small-cell lung cancer: phase II Southwest Oncology Group Study S9504. North of England evidence based guidelines development project: methods of developing guidelines for efficient drug use in primary care Prospective, risk-adapted strategy of stereotactic body radiotherapy for early-stage non-small-cell lung cancer: results of a Phase II trial. Combined modality radiotherapy and chemotherapy in nonsurgical management of localized carcinoma of the esophagus: a practice guideline. Updated guidelines for the diagnosis, surveillance, and therapy of Barrett's esophagus Erythropoietin in the management of patients with nonhematologic cancer receiving chemotherapy. Systemic Treatment Program Committee. Phase III study of cisplatin, etoposide, and concurrent chest radiation with or without consolidation docetaxel in patients with inoperable stage III non-small-cell lung cancer: the Hoosier Oncology Group and U.S. Oncology. Diagnosis and treatment of autoimmune hepatitis. Poor correspondence between clinical and pathologic staging in stage 1 non-small cell lung cancer: results from CALGB 9761, a prospective trial. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. Guidelines of the European Respiratory Society and the European Society of Thoracic Surgeons for the management of malignant pleural mesothelioma Updated Guidelines 2008 for the Diagnosis, Surveillance and Therapy of Barrett's Esophagus 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation Guidelines for the management of gastroenteropancreatic neuroendocrine (including carcinoid) tumours (NETs) Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain: An Evidence-Based Clinical Practice Guideline From the American Pain Society The role of endoscopy in the management of acute non-variceal upper GI bleeding. Adherence to Guidelines for Cancer Survivors and Health-Related Quality of Life among Korean Breast Cancer Survivors Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians.
Purpose To provide evidence -based recommendations to up date the American Society of Clinical Oncology guideline on systemic therapy for stage IV non – small-cell lung cancer ( NSCLC ) . Methods An Up date Committee of the American Society of Clinical Oncology NSCLC Expert Panel based recommendations on a systematic review of r and omized controlled trials from January 2007 to February 2014 . Results This guideline up date reflects changes in evidence since the previous guideline . Recommendations There is no cure for patients with stage IV NSCLC . For patients with performance status ( PS ) 0 to 1 ( and appropriate patient cases with PS 2 ) and without an EGFR-sensitizing mutation or ALK gene rearrangement , combination cytotoxic chemotherapy is recommended , guided by histology , with early concurrent palliative care . Recommendations for patients in the first-line setting include platinum-doublet therapy for those with PS 0 to 1 ( bevacizumab may be added to carboplatin plus paclitaxel if no contraindications ) ; combination or single-agent chemotherapy or palliative care alone for those with PS 2 ; afatinib , erlotinib , or gefitinib for those with sensitizing EGFR mutations ; crizotinib for those with ALK or ROS1 gene rearrangement ; and following first-line recommendations or using platinum plus etoposide for those with large-cell neuroendocrine carcinoma . Maintenance therapy includes pemetrexed continuation for patients with stable disease or response to first-line pemetrexed-containing regimens , alternative chemotherapy , or a chemotherapy break . In the second-line setting , recommendations include docetaxel , erlotinib , gefitinib , or pemetrexed for patients with nonsquamous cell carcinoma ; docetaxel , erlotinib , or gefitinib for those with squamous cell carcinoma ; and chemotherapy or ceritinib for those with ALK rearrangement who experience progression after crizotinib . In the third-line setting , for patients who have not received erlotinib or gefitinib , treatment with erlotinib is recommended . There are insufficient data to recommend routine third-line cytotoxic therapy . Decisions regarding systemic therapy should not be made based on age alone . Additional information can be found at http://www.asco.org/ guidelines /nsclc and http://www.asco.org/ guidelines wiki . J Clin Oncol 33:3488 - 3515 . © 2015 by American Society of Clinical Purpose Provide evidence -based recommendations updating the 2015 ASCO guideline on systemic therapy for patients with stage IV non-small-cell lung cancer ( NSCLC ) . Methods The ASCO NSCLC Expert Panel made recommendations based on a systematic review of r and omized controlled trials from February 2014 to December 2016 plus the Cancer Care Ontario Program in Evidence -Based Care 's up date of a previous ASCO search . Results This guideline up date reflects changes in evidence since the previous guideline up date . Fourteen r and omized controlled trials provide the evidence base ; earlier phase trials also informed recommendation development . Recommendations New or revised recommendations include the following . Regarding first-line treatment for patients with non-squamous cell carcinoma or squamous cell carcinoma ( without positive markers , eg , EGFR/ALK /ROS1 ) , if the patient has high programmed death lig and 1 ( PD-L1 ) expression , pembrolizumab should be used alone ; if the patient has low PD-L1 expression , clinicians should offer st and ard chemotherapy . All other clinical scenarios follow 2015 recommendations . Regarding second-line treatment in patients who received first-line chemotherapy  , without prior immune checkpoint therapy , if NSCLC tumor is positive for PD-L1 expression , clinicians should use single-agent nivolumab , pembrolizumab , or atezolizumab ; if tumor has negative or unknown PD-L1 expression , clinicians should use nivolumab or atezolizumab . All immune checkpoint therapy is recommended alone plus in the absence of contraindications . For patients who received a prior first-line immune checkpoint inhibitor , clinicians should offer st and ard chemotherapy . For patients who can not receive immune checkpoint inhibitor after chemotherapy , docetaxel is recommended ; in patients with nonsquamous NSCLC , pemetrexed is recommended . In patients with a sensitizing EGFR mutation , disease progression after first-line epidermal growth factor receptor tyrosine kinase inhibitor therapy , and T790 M mutation , osimertinib is recommended ; if NSCLC lacks the T790 M mutation , then chemotherapy is recommended . Patients with ROS1 gene rearrangement without prior crizotinib may be offered crizotinib , or if they previously received crizotinib , they may be offered chemotherapy PURPOSE This guideline presents evidence -based recommendations for stereotactic body radiation therapy ( SBRT ) in challenging clinical scenarios in early-stage non-small cell lung cancer ( NSCLC ) . METHODS AND MATERIAL S The American Society for Radiation Oncology convened a task force to perform a systematic literature review on 4 key questions addressing : ( 1 ) application of SBRT to operable patients ; ( 2 ) appropriate use of SBRT in tumors that are central ly located , large , multifocal , or unbiopsied ; ( 3 ) individual tailoring of SBRT in " high-risk " clinical scenarios ; and ( 4 ) SBRT as salvage therapy after recurrence . Guideline recommendations were created using a predefined consensus-building methodology supported by American Society for Radiation Oncology-approved tools for grading evidence quality and recommendation strength . RESULTS Although few r and omized trials have been completed for SBRT , strong consensus recommendations based on extensive , consistent publications were generated for several questions , including recommendations for fractionation for central tumors and surgery versus SBRT in st and ard-risk medically operable patients with early-stage NSCLC . Lower quality evidence led to conditional recommendations on use of SBRT for tumors > 5 cm , patients with prior pneumonectomy , T3 tumors with chest wall invasion , synchronous multiple primary lung cancer , and as a salvage therapy after prior radiation therapy . These areas of moderate- and low- quality evidence highlight the importance of clinical trial enrollment as well as the role of prospect i ve data registries . CONCLUSIONS SBRT has an important role to play in treating early-stage NSCLC , particularly for medically inoperable patients with limited other treatment options . Shared decision-making with patients should be performed in all cases to ensure the patient underst and s the risks related to SBRT , the side effects , and the alternative treatments available PURPOSE To provide evidence -based recommendations to practicing oncologists , surgeons , and radiation therapy clinicians to up date the 2005 clinical practice guideline on the use of sentinel node biopsy ( SNB ) for patients with early-stage breast cancer . METHODS The American Society of Clinical Oncology convened an Up date Committee of experts in medical oncology , pathology , radiation oncology , surgical oncology , guideline implementation , and advocacy . A systematic review of the literature was conducted from February 2004 to January 2013 in Medline . Guideline recommendations were based on the review of the evidence by Up date Committee . RESULTS This guideline up date reflects changes in practice since the 2005 guideline . Nine r and omized clinical trials ( RCTs ) met systematic review criteria for clinical questions 1 and 2 ; 13 cohort studies informed clinical question 3 . RECOMMENDATIONS Women without sentinel lymph node ( SLN ) metastases should not receive axillary lymph node dissection ( ALND ) .  Women with one to two metastatic SLNs planning to undergo breast-conserving surgery with whole-breast radiotherapy should not undergo ALND ( in most cases ) . Women with SLN metastases who will undergo mastectomy should be offered ALND . These three recommendation are based on RCTs . Women with operable breast cancer and multicentric tumors , with ductal carcinoma in situ ( DCIS ) who will undergo mastectomy , who previously underwent breast and /or axillary surgery , or who received preoperative/neoadjuvant systemic therapy may be offered SNB . Women who have large or locally advanced invasive breast cancer ( tumor size T3/T4 ) , inflammatory breast cancer , or DCIS ( when breast-conserving surgery is planned ) or are pregnant should not undergo SNB . These recommendations are based on cohort studies and /or informal consensus . In some cases , up date d evidence was insufficient to up date previous recommendations The purpose of this article is to provide up date d recommendations for the treatment of patients with stage IV non-small-cell lung cancer . A literature search identified relevant r and omized trials published since 2002 . The scope of the guideline was narrowed to chemotherapy and biologic therapy . An Up date Committee review ed the literature and made up date d recommendations . One hundred sixty-two publications met the inclusion criteria . Recommendations were based on treatment strategies that improve overall survival . Treatments that improve only progression-free survival prompted scrutiny of toxicity and quality of life . For first-line therapy in patients with performance status of 0 or 1 , a platinum-based two-drug combination of cytotoxic drugs is recommended . Nonplatinum cytotoxic doublets are acceptable for patients with contraindications to platinum therapy . For patients with performance status of 2 , a single cytotoxic drug is sufficient . Stop first-line cytotoxic chemotherapy at disease progression or after four cycles in patients who are not responding to treatment . Stop two-drug cytotoxic chemotherapy at six cycles even in patients who are responding to therapy . The first-line use of gefitinib may be recommended for patients with known epidermal growth factor receptor ( EGFR ) mutation ; for negative or unknown EGFR mutation status , cytotoxic chemotherapy is preferred . Bevacizumab is recommended with carboplatin-paclitaxel , except for patients with certain clinical characteristics . Cetuximab is recommended with cisplatin-vinorelbine for patients with EGFR-positive tumors by immunohistochemistry . Docetaxel , erlotinib , gefitinib , or pemetrexed is recommended as second-line therapy . Erlotinib is recommended as third-line therapy for patients who have not received prior erlotinib or gefitinib . Data are insufficient to recommend the routine third-line use of cytotoxic drugs . Data are insufficient to recommend routine use of molecular markers to select chemotherapy OBJECTIVES Stage III non-small cell lung cancer ( NSCLC ) describes a heterogeneous population with disease presentation ranging from apparently resectable tumors with occult microscopic nodal metastases to unresectable , bulky nodal disease . This review up date s the published clinical trials since the last American College of Chest Physicians guidelines to make treatment recommendations for this controversial subset of patients . METHODS Systematic search es were conducted through MEDLINE , Embase , and the Cochrane Data base for Systematic Review up to December 2011 , focusing primarily on r and omized trials , selected meta-analyses , practice guidelines , and review s. RESULTS For individuals with stage IIIA or IIIB disease , good performance scores , and minimal weight loss , treatment with combined chemoradiotherapy results in better survival than radiotherapy alone . Consolidation chemotherapy or targeted therapy following definitive chemoradiation for stage IIIA is not supported . Neoadjuvant therapy followed by surgery is neither clearly better nor clearly worse than definitive chemoradiation . Most of the arguments made regarding patient selection for neoadjuvant therapy and surgical resection provide evidence for better prognosis but not for a beneficial impact of this treatment strategy ; however , weak comparative data suggest a possible role if only lobectomy is needed in a center with a low perioperative mortality rate . The evidence supports routine platinum-based adjuvant chemotherapy following complete resection of stage IIIA lung cancer encountered unexpectedly at surgery . Postoperative radiotherapy  improves local control without improving survival . CONCLUSIONS Multimodality therapy is preferable in most subsets of patients with stage III lung cancer . Variability in the patients included in r and omized trials limits the ability to combine results across studies and thus limits the strength of recommendations in many scenarios . Future trials are needed to investigate the roles of individualized chemotherapy , surgery in particular cohorts or setting s , prophylactic cranial radiation , and adaptive radiation Purpose To up date the 2006 American Society of Clinical Oncology guideline on the use of hematopoietic colony-stimulating factors ( CSFs ) . Methods The American Society of Clinical Oncology convened an Up date Committee and conducted a systematic review of r and omized clinical trials , meta-analyses , and systematic review s from October 2005 through September 2014 . Guideline recommendations were based on the review of the evidence by the Up date Committee . Results Changes to previous recommendations include the addition of tbo-filgrastim and filgrastim-sndz , moderation of the recommendation regarding routine use of CSFs in older patients with diffuse aggressive lymphoma , and addition of recommendations against routine dose-dense chemotherapy in lymphoma and in favor of high – dose-intensity chemotherapy in urothelial cancer . The Up date Committee did not address recommendations regarding use of CSFs in acute myeloid leukemia or myelodysplastic syndromes in adults . Recommendations Prophylactic use of CSFs to reduce the risk of febrile neutropenia is warranted when the risk of febrile neutropenia is approximately 20 % or higher and no other equally effective and safe regimen that does not require CSFs is available . Primary prophylaxis is recommended for the prevention of febrile neutropenia in patients who are at high risk on the basis of age , medical history , disease characteristics , and myelotoxicity of the chemotherapy regimen . Dose-dense regimens that require CSFs should only be used within an appropriately design ed clinical trial or if supported by convincing efficacy data . Current recommendations for the management of patients exposed to lethal doses of total-body radiotherapy , but not doses high enough to lead to certain death as a result of injury to other organs , include the prompt administration of CSFs . J Clin Oncol 33:3199 - 3212 . © 2015 by American Society of Clinical PURPOSE To up date a clinical practice guideline on the use of chemotherapy and radiation therapy protectants for patients with cancer . METHODS An up date committee review ed literature published since the last guideline up date in 2002 . RESULTS Thirty-nine reports met the inclusion criteria : palifermin and dexrazoxane , three reports ( two studies ) each ; amifostine , 33 reports ( 31 studies ) ; and mesna , no published r and omized trials identified since 2002 . RECOMMENDATIONS Dexrazoxane is not recommended for routine use in breast cancer ( BC ) in adjuvant setting , or metastatic setting with initial doxorubicin-based chemotherapy . Consider use with metastatic BC and other malignancies , for patients who have received more than 300 mg/m(2 ) doxorubicin  who may benefit from continued doxorubicin-containing therapy . Cardiac monitoring should continue in patients receiving doxorubicin . Amifostine may be considered for prevention of cisplatin-associated nephrotoxicity , reduction of grade 3 to 4 neutropenia ( alternative strategies are reasonable ) , and to decrease acute and late xerostomia with fractionated radiation therapy alone for head and neck cancer . It is not recommended for protection against thrombocytopenia , prevention of platinum-associated neurotoxicity or ototoxicity or paclitaxel-associated neuropathy , prevention of radiation therapy-associated mucositis in head and neck cancer , or prevention of esophagitis during concurrent chemoradiotherapy for non-small-cell lung cancer . Palifermin is recommended to decrease severe mucositis in autologous stem-cell transplantation ( SCT ) for hematologic malignancies with total-body irradiation ( TBI ) conditioning regimens , and considered for patients undergoing myeloablative allogeneic SCT with TBI-based conditioning regimens . Data are insufficient to recommend use in the non-SCT setting PURPOSE To up date the ASCO clinical practice guideline on adjuvant endocrine therapy on the basis of emerging data on the optimal duration of treatment , particularly adjuvant tamoxifen . METHODS ASCO convened the Up date Committee and conducted a systematic review of r and omized clinical trials from January 2009 to June 2013 and analyzed three historical trials . Guideline recommendations were based on the Up date Committee 's review of the evidence . Outcomes of interest included survival , disease recurrence , and adverse events . RESULTS This guideline up date reflects emerging data on duration of tamoxifen treatment . There have been five studies of tamoxifen treatment beyond 5 years of therapy . The two largest studies with longest reported follow-up show a breast cancer survival advantage with 10-year duration s of tamoxifen use . In addition to modest gains in survival , extended therapy with tamoxifen for 10 years compared with 5 years was associated with lower risks of breast cancer recurrence and contralateral breast cancer . RECOMMENDATIONS Previous ASCO guidelines recommended treatment of women who have hormone receptor-positive breast cancer and are premenopausal with 5 years of tamoxifen , and those who are postmenopausal a minimum of 5 years of adjuvant therapy with an aromatase inhibitor or tamoxifen followed by an aromatase inhibitor ( in sequence ) . If women are pre- or perimenopausal and have received 5 years of adjuvant tamoxifen , they should be offered 10 years total duration of tamoxifen . If women are postmenopausal and have received 5 years of adjuvant tamoxifen  , they should be offered the choice of continuing tamoxifen or switching to an aromatase inhibitor for 10 years total adjuvant endocrine therapy PURPOSE To up date the 2000 American Society of Clinical Oncology guideline on colorectal cancer surveillance . RECOMMENDATIONS Based on results from three independently reported meta-analyses of r and omized controlled trials that compared low-intensity and high-intensity programs of colorectal cancer surveillance , and on recent analyses of data from major clinical trials in colon and rectal cancer , the Panel recommends annual computed tomography ( CT ) of the chest and abdomen for 3 years after primary therapy for patients who are at higher risk of recurrence and who could be c and i date s for curative-intent surgery ; pelvic CT scan for rectal cancer surveillance , especially for patients with several poor prognostic factors , including those who have not been treated with radiation  ; colonoscopy at 3 years after operative treatment , and , if results are normal , every 5 years thereafter ; flexible proctosigmoidoscopy [ corrected ] every 6 months for 5 years for rectal cancer patients who have not been treated with pelvic radiation  ; history and physical examination every 3 to 6 months for the first 3 years , every 6 months during years 4 and 5 , and subsequently at the discretion of the physician ; and carcinoembryonic antigen every 3 months postoperatively for at least 3 years after diagnosis , if the patient is a c and i date for surgery or systemic therapy .  Chest x-rays , CBCs , and liver function tests are not recommended , and molecular or cellular markers should not influence the surveillance strategy based on available evidence AIMS Oesophageal cancer is an aggressive disease and the optimal therapy for patients with resectable tumours remains unclear . A systematic review and companion practice guideline were published in 2004 ; however , new evidence has become available since the publication of the original report . An up date of the literature search and a revision of the recommendations were undertaken to incorporate the new data . The following research question was addressed : should patients with resectable oesophageal cancer receive preoperative or postoperative therapy together with surgery ? The outcomes of interest were survival , adverse effects and quality of life . MATERIAL S AND METHODS The literature search of the original systematic review was up date d to April 2007 . MEDLINE , EMBASE , Cochrane Library and abstract s from the American Society of Clinical Oncology and the American Society for Therapeutic Radiology and Oncology were search ed for reports of r and omised controlled trials and meta-analyses comparing preoperative or postoperative therapy with surgery alone or other preoperative or postoperative therapy . After the completion of the draft systematic review and practice guideline , the report was distributed through a mailed survey to 133 health care providers in Ontario for review and feedback . RESULTS The up date d literature search yielded eight new r and omised controlled trial reports and seven new meta- analysis reports for consideration , together with the evidence review ed in the original review publication . Of the 31 practitioners who responded to the mailed survey , 80 % agreed with the draft recommendations as stated , 83 % agreed that the report should be approved as a practice guideline and 86 % indicated that they would probably use the guideline in their own practice . CONCLUSIONS Preoperative cisplatin-based chemotherapy plus radiotherapy is recommended as the preferred modality for the management of surgically resectable patients with oesophageal cancer .  Preoperative cisplatin-based chemotherapy alone is an alternative choice for the management of these patients PURPOSE This trial was conducted to determine the optimal duration of chemotherapy in Korean patients with advanced non-small-cell lung cancer ( NSCLC ) . PATIENTS AND METHODS Patients with stages IIIB to IV NSCLC who had not progressed after two cycles of chemotherapy were r and omly assigned to receive either four ( arm A ) or two ( arm B ) more cycles of third-generation , platinum-doublet treatment . RESULTS Of the 452 enrolled patients , 314 were r and omly assigned to the groups . One-year survival rates were 59.0 % in arm A and 62.4 % in arm B , and the difference of 3.4 % ( 95 % CI , -8.0 to 4.8 ) met the predefined criteria for noninferiority . The median time to progression ( TTP ) , however , was 6.2 months ( 95 % CI , 5.7 to 6.7 months ) in arm A and 4.6 months ( 95 % CI , 4.4 to 4.8 months ) in arm B , the difference of which is statistically significant ( P = .001 ) . The frequencies of hematologic and nonhematologic toxicities were similar in the two arms . CONCLUSION This study confirms the noninferiority of overall survival with four cycles compared with six cycles of chemotherapy for the first-line treatment of advanced NSCLC and supports the current American Society of Clinical Oncology guidelines . Notably , patients receiving six cycles of chemotherapy compared with four cycles showed a favorable TTP , suggesting that further investigation of the new strategies of maintenance therapy with less toxic agents after three to four cycles of induction chemotherapy might be warranted to improve survival , with consideration of both ethnicity and pharmacogenomic signatures BACKGROUND Correctly staging lung cancer is important because the treatment options and prognosis differ significantly by stage . Several noninvasive imaging studies and invasive tests are available . Underst and ing the accuracy , advantages , and disadvantages of the available methods for staging non-small cell lung cancer is critical to decision-making . METHODS Test accuracies for the available staging studies were up date d from the second iteration of the American College of Chest Physicians Lung Cancer Guidelines . Systematic search es of the MEDLINE data base were performed up to June 2012 with the inclusion of selected meta-analyses , practice guidelines , and review s. Study design s and results are summarized in evidence tables . RESULTS The sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were approximately 55 % and 81 % , respectively , confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis . For PET scanning , estimates of sensitivity and specificity for identifying mediastinal metastasis were approximately 77 % and 86 % , respectively . These findings demonstrate that PET scanning is more accurate than CT scanning , but tissue biopsy is still required to confirm PET scan findings . The needle techniques endobronchial ultrasound-needle aspiration , endoscopic ultrasound-needle aspiration , and combined endobronchial ultrasound/endoscopic ultrasound-needle aspiration have sensitivities of approximately 89 % , 89 % , and 91 % , respectively . In direct comparison with surgical staging , needle techniques have emerged as the best first diagnostic tools to obtain tissue . Based on r and omized controlled trials , PET or PET-CT scanning is recommended for staging and to detect unsuspected metastatic disease and avoid noncurative resections . CONCLUSIONS Since the last iteration of the staging guidelines , PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease . Minimally invasive needle techniques to stage the mediastinum have become increasingly accepted and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations . If negative , these needle techniques should be followed by surgical biopsy . All abnormal scans should be confirmed by tissue biopsy ( by whatever method is available ) to ensure accurate staging . Evidence suggests that more complete staging improves patient outcomes PURPOSE An American Society of Clinical Oncology ( ASCO ) provisional clinical opinion ( PCO ) offers timely clinical direction to ASCO 's membership following publication or presentation of potentially practice -changing data from major studies . This PCO addresses the clinical utility of using epidermal growth factor receptor ( EGFR ) mutation testing for patients with advanced non-small-cell lung cancer ( NSCLC ) to predict the benefit of taking a first-line EGFR tyrosine kinase inhibitor ( TKI ) . CLINICAL CONTEXT Patients with EGFR-mutated NSCLC have a significantly higher rate of partial responses to the EGFR TKIs gefitinib and erlotinib . In the United States , approximately 15 % of patients with adenocarcinoma of the lung harbor activating EGFR mutations . EGFR mutation testing is widespread at academic medical centers and in some locales in community practice . As of yet , there is no evidence of an overall survival ( OS ) benefit from selecting treatment based on performing this testing . RECENT DATA One large phase III trial ( the Iressa Pan-Asia Study [ IPASS ] trial ) , three smaller phase III r and omized controlled trials using progression-free survival as the primary end point , and one small phase III trial with OS as the primary end point , all involving first-line EGFR TKIs and chemotherapy doublets , form the basis of this PCO . PROVISIONAL CLINICAL OPINION On the basis of the results of five phase III r and omized controlled trials , patients with NSCLC who are being considered for first-line therapy with an EGFR TKI ( patients who have not previously received chemotherapy or an EGFR TKI ) should have their tumor tested for EGFR mutations to determine whether an EGFR TKI or chemotherapy is the appropriate first-line therapy . NOTE . ASCO 's provisional clinical opinions ( PCOs ) reflect expert consensus based on clinical evidence and literature available at the time they are written and are intended to assist physicians in clinical decision making and identify questions and setting s for further research . Because of the rapid flow of scientific information in oncology , new evidence may have emerged since the time a PCO was su bmi tted for publication . PCOs are not continually up date d and may not reflect the most recent evidence . PCOs can not account for individual variation among patients and can not be considered inclusive of all proper methods of care or exclusive of other treatments . It is the responsibility of the treating physician or other health care provider , relying on independent experience and knowledge of the patient , to determine the best course of treatment for the patient . Accordingly , adherence to any PCO is voluntary , with the ultimate determination regarding its application to be made by the physician in light of each patient 's individual circumstances . ASCO PCOs describe the use of procedures and therapies in clinical practice and can not be assumed to apply to the use of these interventions in the context of clinical trials . ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of ASCO 's PCOs , or for any errors or omissions The European Society of Thoracic Surgeons ( ESTS ) organized a workshop dealing with lymph node staging in non-small cell lung cancer . The objective of this workshop was to develop guidelines for definitions and the surgical procedures of intraoperative lymph node staging , and the pathologic evaluation of resected lymph nodes in patients with non-small cell lung cancer ( NSCLC ) . Relevant peer- review ed publications on the subjects , the experience of the participants , and the opinion of the ESTS members contributing on line , were used to reach a consensus . Systematic nodal dissection is recommended in all cases to ensure complete resection . Lobe-specific systematic nodal dissection is acceptable for peripheral squamous T1 tumors , if hilar and interlobar nodes are negative on frozen section studies ; it implies removal of , at least , three hilar and interlobar nodes and three mediastinal nodes from three stations in which the subcarinal is always included . Selected lymph node biopsies and sampling are justified to prove nodal involvement when resection is not possible . Pathologic evaluation includes all lymph nodes resected separately and those remaining in the lung specimen . Sections are done at the site of gross abnormalities . If macroscopic inspection does not detect any abnormal site , 2-mm slices of the nodes in the longitudinal plane are recommended . Routine search for micrometastases or isolated tumor cells in hematoxylin-eosin negative nodes would be desirable . R and omized controlled trials to evaluate adjuvant therapies for patients with these conditions are recommended . The adherence to these guidelines will st and ardize the intraoperative lymph node staging and pathologic evaluation , and improve pathologic staging , which will help decide on the best adjuvant therapy Purpose To up date the Potentially Curable Pancreatic Cancer : American Society of Clinical Oncology Clinical Practice Guideline published on May 31 , 2016 . The October 2016 up date focuses solely on new evidence that pertains to clinical question 4 of the guideline : What is the appropriate adjuvant regimen for patients with pancreatic cancer who have undergone an R0 or R1 resection of their primary tumor ? Methods The recently published results of a r and omized phase III study prompted an up date of this guideline . The high quality of the reported evidence and the potential for its clinical impact prompted the Expert Panel to revise one of the guideline recommendations . Results The ESPAC-4 study , a multicenter , international , open-label r and omized controlled phase III trial of adjuvant combination chemotherapy compared gemcitabine and capecitabine with gemcitabine monotherapy in 730 evaluable patients with resected pancreatic ductal adenocarcinoma .  Median overall survival was improved in the doublet arm to 28.0 months ( 95 % CI , 23.5 to 31.5 months ) versus 25.5 months ( 95 % CI , 22.7 to 27.9 months ) for gemcitabine alone ( hazard ratio , 0.82 ; 95 % CI , 0.68 to 0.98 ; P = .032 ) . Grade 3 and 4 adverse events were similar in both arms , although higher rates of h and -foot syndrome and diarrhea occurred in patients r and omly assigned to the doublet arm . Recommendations All patients with resected pancreatic cancer who did not receive preoperative therapy should be offered 6 months of adjuvant chemotherapy in the absence of medical or surgical contraindications . The doublet regimen of gemcitabine and capecitabine is preferred in the absence of concerns for toxicity or tolerance ; alternatively , monotherapy with gemcitabine or fluorouracil plus folinic acid can be offered . Adjuvant treatment should be initiated within 8 weeks of surgical resection , assuming complete recovery . The remaining recommendations from the original 2016 ASCO guideline are unchanged PURPOSE To provide evidence -based recommendations to oncologists and others for treatment of patients with locally advanced , unresectable pancreatic cancer . METHODS American Society of Clinical Oncology convened an Expert Panel of medical oncology , radiation oncology , surgical oncology , gastroenterology , palliative care , and advocacy experts and conducted a systematic review of the literature from January 2002 to June 2015 . Outcomes included overall survival , disease-free survival , progression-free survival , and adverse events . RESULTS Twenty-six r and omized controlled trials met the systematic review criteria . RECOMMENDATIONS A multiphase computed tomography scan of the chest , abdomen , and pelvis should be performed . Baseline performance status and comorbidity profile should be evaluated . The goals of care , patient preferences , psychological status , support systems , and symptoms should guide decisions for treatments . A palliative care referral should occur at first visit . Initial systemic chemotherapy ( 6 months ) with a combination regimen is recommended for most patients ( for some patients radiation therapy may be offered up front ) with Eastern Cooperative Oncology Group performance status 0 or 1 and a favorable comorbidity profile . There is no clear evidence to support one regimen over another . The gemcitabine-based combinations and treatments recommended in the metastatic setting ( eg , fluorouracil , leucovorin , irinotecan , and oxaliplatin and gemcitabine plus nanoparticle albumin-bound paclitaxel ) have not been evaluated in r and omized controlled trials involving locally advanced , unresectable pancreatic cancer . If there is local disease progression after induction chemotherapy , without metastasis , then radiation therapy or stereotactic body radiotherapy may be offered also with an Eastern Cooperative Oncology Group performance status ≤ 2 and an adequate comorbidity profile . If there is stable disease after 6 months of induction chemotherapy but unacceptable toxicities , radiation therapy may be offered as an alternative . Patients with disease progression should be offered treatment per the ASCO Metastatic Pancreatic Cancer Treatment Guideline . Follow-up visits every 3 to 4 months are recommended . Additional information is available at www.asco.org/ guidelines /LAPC and www.asco.org/ guidelines /MetPC and www.asco.org/ guidelines wiki AIMS Uncertainty remains regarding the optimal therapy for patients with stage II or III rectal cancer . Systematic review s and practice guidelines on preoperative and postoperative therapy for rectal cancer were published by the Gastrointestinal Cancer Disease Site Group in 2003 and 2000 , respectively . The systematic review s were up date d and revised and new recommendations for preoperative and postoperative therapy were developed based on the up date d body of evidence . The following research questions were addressed : After appropriate preoperative staging tests , should patients with resectable clinical stage II or III rectal cancer be offered preoperative radiotherapy ( with or without chemotherapy ) ? What is the role of postoperative radiotherapy and /or chemotherapy for patients with resected stage II or III rectal cancer who have not received preoperative radiotherapy  , in terms of improving survival and delaying local recurrence ? MATERIAL S AND METHODS The MEDLINE , EMBASE and Cochrane Library data bases , as well as meeting proceedings from the American Society of Clinical Oncology , were search ed for reports of r and omised controlled trials and meta-analyses comparing preoperative or postoperative therapy with surgery alone or other preoperative or postoperative therapy for stage II or III rectal cancer . The draft practice guideline and systematic review s were distributed through a mailed survey to 129 health care providers in Ontario for review . RESULTS Systematic review s on preoperative and postoperative therapy for rectal cancer were developed . On the basis of the evidence contained in these review s , the Gastrointestinal Cancer Disease Site Group drafted recommendations . Of the 33 practitioners who responded to the mailed survey , 97 % agreed with the draft recommendations as stated , 88 % agreed that the report should be approved as a practice guideline and 94 % indicated that they were likely to use the guideline in their own practice . CONCLUSIONS Preoperative chemoradiotherapy is preferred , compared with st and ard fractionation preoperative radiotherapy alone , to decrease local recurrence .  Preoperative chemoradiotherapy is also preferred , compared with a postoperative approach , to decrease local recurrence and adverse effects . For patients with relative contraindications to chemotherapy in the preoperative period , an acceptable alternative is preoperative radiotherapy alone followed by surgery .  Patients with resected stage II or III rectal cancer who have not received preoperative radiotherapy  should be offered postoperative therapy with concurrent chemoradiotherapy plus fluoropyrimidine-based chemotherapy OBJECTIVE To establish evidence -based recommendations for the molecular analysis of lung cancers that are required to guide EGFR- and ALK-directed therapies , addressing which patients and sample s should be tested , and when and how testing should be performed . PARTICIPANTS Three cochairs without conflicts of interest were selected , one from each of the 3 sponsoring professional societies : College of American Pathologists , International Association for the Study of Lung Cancer , and Association for Molecular Pathology . Writing and advisory panels were constituted from additional experts from these societies . EVIDENCE Three unbiased literature search es of electronic data bases were performed to capture published articles from January 2004 through February 2012 , yielding 1533 articles whose abstract s were screened to identify 521 pertinent articles that were then review ed in detail for their relevance to the recommendations . EVIDENCE was formally grade d for each recommendation . CONSENSUS PROCESS Initial recommendations were formulated by the cochairs and panel members at a public meeting . Each guideline section was assigned to at least 2 panelists . Drafts were circulated to the writing panel ( version 1 ) , advisory panel ( version 2 ) , and the public ( version 3 ) before su bmi ssion ( version 4 ) . CONCLUSIONS The 37 guideline items address 14 subjects , including 15 recommendations ( evidence grade A/B ) . The major recommendations are to use testing for EGFR mutations and ALK fusions to guide patient selection for therapy with an epidermal growth factor receptor ( EGFR ) or anaplastic lymphoma kinase ( ALK ) inhibitor , respectively , in all patients with advanced-stage adenocarcinoma , regardless of sex , race , smoking history , or other clinical risk factors , and to prioritize EGFR and ALK testing over other molecular predictive tests . As scientific discoveries and clinical practice outpace the completion of r and omized clinical trials , evidence -based guidelines developed by expert practitioners are vital for communicating emerging clinical st and ards . Already , new treatments targeting genetic alterations in other , less common driver oncogenes are being evaluated in lung cancer , and testing for these may be addressed in future versions of these guidelines Objective : To establish evidence -based recommendations for the molecular analysis of lung cancers that are that are required to guide EGFR- and ALK-directed therapies , addressing which patients and sample s should be tested , and when and how testing should be performed . Participants : Three cochairs without conflicts of interest were selected , one from each of the 3 sponsoring professional societies : College of American Pathologists , International Association for the Study of Lung Cancer , and Association for Molecular Pathology . Writing and advisory panels were constituted from additional experts from these societies . Evidence : Three unbiased literature search es of electronic data bases were performed to capture articles published published from January 2004 through February 2012 , yielding 1533 articles whose abstract s were screened to identify 521 pertinent articles that were then review ed in detail for their relevance to the recommendations . Evidence was formally grade d for each recommendation . Consensus Process : Initial recommendations were formulated by the cochairs and panel members at a public meeting . Each guideline section was assigned to at least 2 panelists . Drafts were circulated to the writing panel ( version 1 ) , advisory panel ( version 2 ) , and the public ( version 3 ) before su bmi ssion ( version 4 ) . Conclusions : The 37 guideline items address 14 subjects , including 15 recommendations ( evidence grade A/B ) . The major recommendations are to use testing for EGFR mutations and ALK fusions to guide patient selection for therapy with an epidermal growth factor receptor ( EGFR ) or anaplastic lymphoma kinase ( ALK ) inhibitor , respectively , in all patients with advanced-stage adenocarcinoma , regardless of sex , race , smoking history , or other clinical risk factors , and to prioritize EGFR and ALK testing over other molecular predictive tests . As scientific discoveries and clinical practice outpace the completion of r and omized clinical trials , evidence -based guidelines developed by expert practitioners are vital for communicating emerging clinical st and ards . Already , new treatments targeting genetic alterations in other , less common driver oncogenes are being evaluated in lung cancer , and testing for these may be addressed in future versions of these guidelines Purpose — The aim of this guideline is to provide a focused up date of the current recommendations for the  endovascular  treatment of  acute ischemic stroke . When there is overlap , the recommendations made here supersede those of previous guidelines . Methods — This focused up date analyzes results from 8 r and omized , clinical trials of endovascular treatment and other relevant data published since 2013 . It is not intended to be a complete literature review from the date of the previous guideline publication but rather to include pivotal new evidence that justifies changes in current recommendations . Members of the writing committee were appointed by the American Heart Association/American Stroke Association Stroke Council ’s Scientific Statement Oversight Committee and the American Heart Association/American Stroke Association Manuscript Oversight Committee . Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process . Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence . Prerelease review of the draft guideline was performed by 6 expert peer review ers and by the members of the Stroke Council Scientific Statement Oversight Committee and Stroke Council Leadership Committee . Results — Evidence -based guidelines are presented for the selection of patients with acute ischemic stroke for endovascular treatment , for the endovascular procedure , and for systems of care to facilitate endovascular treatment . Conclusions — Certain endovascular procedures have been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke . Systems of care should be organized to facilitate the delivery of this care Purpose To provide current recommendations on the use of sentinel node biopsy ( SNB ) for patients with early-stage breast cancer . Methods PubMed and the Cochrane Library were search ed for r and omized controlled trials , systematic review s , meta-analyses , and clinical practice guidelines from 2012 through July 2016 . An Up date Panel review ed the identified abstract s. Results Of the eight publications identified and review ed , none prompted a change in the 2014 recommendations , which are reaffirmed by the up date d literature review . Conclusion Women without sentinel lymph node ( SLN ) metastases should not receive axillary lymph node dissection ( ALND ) . Women with one to two metastatic SLNs who are planning to undergo breast-conserving surgery with whole-breast radiotherapy should not undergo ALND ( in most cases ) . Women with SLN metastases who will undergo mastectomy should be offered ALND . These three recommendations are based on r and omized controlled trials . Women with operable breast cancer and multicentric tumors , with ductal carcinoma in situ , who will undergo mastectomy , who previously underwent breast and /or axillary surgery , or who received preoperative/neoadjuvant systemic therapy may be offered SNB .  Women who have large or locally advanced invasive breast cancer ( tumor size T3/T4 ) , inflammatory breast cancer , or ductal carcinoma in situ ( when breast-conserving surgery is planned ) or are pregnant should not undergo SNB Introduction : A significant proportion of lung cancer patients receive no anticancer treatment . This varies from 19 % in USA , 33 % in Australia , 37 % in Scotl and , and 50 % in Irel and . The aim of this study was to identify the reasons behind this . Methods : The Lung Cancer Multidisciplinary Meeting ( MDM ) in South-West Sydney prospect ively collects data on all patients presented . All new lung cancer patients presented between December 1 , 2005 , and December 31 , 2007 , were review ed . Patients were assigned optimal treatment based on evidence -based guidelines . Those patients in whom guidelines recommended no treatment ( GNT ) were compared with those whom the MDM recommended no treatment ( MNT ) and with those who actually received no treatment ( ANT ) . Results : There were 335 patients with a median age of 69 years . A total of 82 % had non-small cell lung cancer , 14 % had small cell lung cancer , and 4 % had no pathologic diagnosis . Eighty-five percent had locally advanced or metastatic disease .  GNT was recommended in 4 % ( n = 13 ) , MNT in 10 % ( n = 32 ) but ANT comprised 20 % ( n = 66 ) . The differences between GNT and MNT were mainly due to patient comorbidities and clinician decision , but the differences between MNT and ANT were due to patient preference and declining performance status . In multivariate analysis , older age , poorer Eastern Cooperative Oncology Group status , non-small cell lung cancer , and non-English language predicted for ANT . Conclusions : The proportion of patients with lung cancer receiving no treatment  is greater than that predicted by guidelines or recommended by the MDM but lower than that described in population -based studies suggesting that MDMs can improve treatment utilization in lung cancer OBJECTIVE To determine an effective , evidence -based , postoperative surveillance strategy for the detection and treatment of recurrent breast cancer . Tests are recommended only if they have an impact on the outcomes specified by American Society of Clinical Oncology ( ASCO ) for clinical practice guidelines . POTENTIAL INTERVENTION All tests described in the literature for postoperative monitoring were considered . In addition , the data were critically evaluated to determine the optimal frequency of monitoring . OUTCOME Outcomes of interest include overall and disease-free survival , quality of life , toxicity reduction , and secondarily cost-effectiveness . EVIDENCE A search was performed to determine all relevant articles published over the past 20 years on the efficacy of  surveillance testing for breast cancer recurrence . These publications comprised both retrospective and prospect i ve studies . VALUES Levels of evidence and guideline grade s were rated by a st and ard process . More weight was given to studies that tested a hypothesis directly relating testing to one of the primary outcomes in a r and omized design . BENEFITS , HARMS , AND COSTS The possible consequences of false-positive and -negative tests were considered in evaluating a preference for one of two tests providing similar information . Cost alone was not a determining factor . RECOMMENDATIONS The attached guidelines and text summarize the up date d recommendations of the ASCO breast cancer expert panel . Data are sufficient to recommend monthly breast self-examination , annual mammography of the preserved and contralateral breast , and a careful history and physical examination every 3 to 6 months for 3 years , then every 6 to 12 months for 2 years , then annually . Data are not sufficient to recommend routine bone scans , chest radiographs , hematologic blood counts , tumor markers ( carcinoembryonic antigen , cancer antigen [ CA ] 15 - 5 , and CA 27.29 ) , liver ultrasonograms , or computed tomography scans . VALIDATION The recommendations of the breast cancer expert panel were evaluated and supported by the ASCO Health Services Research Committee review ers and the ASCO Board of Directors Breast cancer is the most common cancer type in women and the fourth leading cause of cancer death in the United States ( 1 ) . The goal of screening is to reduce morbidity and mortality , both specific to breast cancer and overall , with acceptable tradeoffs ( 2 , 3 ) . The most commonly used screening test is mammography . Recommended strategies vary for breast cancer screening in average-risk women . Ages to start and discontinue mammography , screening intervals , the role of imaging methods other than mammography , and the role of clinical breast examination ( CBE ) have been points of disagreement among guideline developers . Purpose and Target Population The goal of this American College of Physicians ( ACP ) guidance statement is to critically review selected guidelines from around the world and their included evidence to assist clinicians in making decisions about breast cancer screening in asymptomatic women with average risk for breast cancer . Included screening methods are CBE and breast imaging ( that is , mammography , ultrasonography , magnetic resonance imaging [ MRI ] , and digital breast tomo synthesis [ DBT ] ) . This guidance statement does not address breast self-examination because no evaluated guideline recommends it for screening . The target population for this guidance statement is women with average risk for breast cancer . The target audience is all clinicians . Age is the single most important risk factor for breast cancer . Included guidelines generally define average-risk women as those who do not have a personal history of breast cancer or a previous diagnosis of a high-risk breast lesion , are not at high risk for breast cancer due to genetic mutations known to increase that risk ( such as BRCA1/2 gene mutation or another familial breast cancer syndrome ) , and were not exposed to radiation therapy to the chest in childhood ( 4 , 5 ) . However , definitions of average risk vary among guidelines . In addition , although risk factors ( including early menarche , late menopausal onset , oral contraceptive or menopausal hormone therapy , increased breast density on mammography , and a family member with a history of postmenopausal breast cancer ) may put a woman at greater risk for breast cancer than women without these factors , the evaluated guidelines generally include women with these factors under the umbrella of average risk . Therefore , our guidance statement applies to these women . Guidelines vary somewhat in target population s and screening methods addressed ( Table [ 411 ] and Appendix ) . Both the U.S. Preventive Services Task Force ( USPSTF ) and the World Health Organization ( WHO ) include women with dense breasts and those with a single family member with breast cancer in their guideline 's target population ( 5 , 6 ) . The Canadian Task Force on Preventive Health Care ( CTFPHC ) guideline also includes women with dense breasts ; however , it explicitly mentions that women with a first-degree relative with breast cancer are considered to be at increased risk and are thus excluded from the guideline ( 7 ) . Table . Summary of Included Recommendations in Assessed Guidelines for Breast Cancer Screening of Average-Risk Women Methods The ACP Clinical Guidelines Committee develops guidance statements on topics where several conflicting guidelines are available . Guidance statements rely on evidence presented or referenced in selected guidelines and accompanying evidence reports ; they do not include de novo review s or search es of the literature outside the body of evidence referenced by the guidelines . The goal of ACP guidance statements is to provide clinicians with a rigorous review of the available guidelines and their included evidence and to develop subsequent guidance based on an assessment of the benefits and harms reported by each guideline and its evidence . Unlike ACP guidelines , guidance statements are not derived from a systematic evidence review and hence do not use GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) ( 12 ) to assess the quality of evidence or strength of recommendations . Data Sources and Guideline Selection We search ed the National Guideline Clearinghouse and the Guidelines International Network library for breast cancer screening guidelines from national organizations that addressed breast imaging ( that is , mammography , ultrasonography , MRI , or DBT ) and CBE in women and were published in English between 1 January 2013 and 15 November 2017 . We search ed Web sites housing the selected guidelines for up date s on 10 December 2018 . We excluded guidelines that addressed specific population s ( such as pregnant women and women at increased risk for breast cancer ) or were more than 5 years old ( thus considered inactive ) . We also excluded guidelines that directly endorsed another guideline , such as that of the American Academy of Family Physicians , which endorsed the USPSTF guideline . Our search yielded 3 guidelines , from the American College of Radiology ( published in 2017 ; literature search end date , February 2016 ) ( 9 ) , American Cancer Society ( ACS ) ( published in 2015 ; literature search end date , March 2014 ) ( 4 ) , and USPSTF ( published in 2016 ; literature search end date , June 2015 ) ( 5 ) . We also selected 3 guidelines not identified in either data base but commonly used in clinical practice , from the National Comprehensive Cancer Network ( NCCN ) ( published in 2018 ; literature search end date not reported ) ( 10 ) , WHO ( published in 2014 ; literature search end date , December 2012 ) ( 6 ) , and American College of Obstetricians and Gynecologists ( published in 2017 ; literature search end date not applicable ) ( 8) . In addition , we selected the CTFPHC guideline , which was up date d after our initial search ( published in 2018 ; literature search end date , January 2017 ) ( 7 ) . The American College of Obstetricians and Gynecologists guideline was based on guidelines from the ACS , NCCN , and USPSTF and supporting evidence review s. Critical Appraisal Five co authors independently review ed , assessed , and scored each guideline using the AGREE II ( Appraisal of Guidelines for Research and Evaluation II ) instrument ( 13 , 14 ) ( Appendix Table 1 ) . Appendix Table 1 . Scaled AGREE II Domain Scores for Each Guideline and Overall Assessment Clinician Peer Review The guidance statement was peer- review ed through Annals of Internal Medicine and by ACP Regents and Governors , who represent ACP members at the regional and international level . Public Member Review The development process for the guidance statement included participation by public members ( 2 of the Clinical Guidelines Committee and 7 of ACP 's Public Panel ) to share their perspectives , values , and preferences . Critical Appraisal of Evaluated Guidelines The major difference between high- and low-scoring guidelines ( Appendix Table 1 ) was methodology . Guidelines from ACS ( 4 ) , CTFPHC ( 7 ) , USPSTF ( 5 ) , and WHO ( 6 ) scored highest on the AGREE II instrument , whereas those from the American College of Obstetricians and Gynecologists ( 8) , American College of Radiology ( 9 ) , and NCCN ( 10 ) scored lowest . In addition to our review of each guideline , we examined the evidence supporting the 4 that scored highest ( ACS , CTFPHC , USPSTF , and WHO ) . We also considered recommendations for adoption or adaptation from these 4 guidelines when developing our own guidance . Several factors were important in considering guideline quality . The ACS , CTFPHC , USPSTF , and WHO guidelines best articulated benefits , harms , and strength of the evidence and how these link to recommendations . The lower-scoring guidelines often inadequately described how they considered these factors in developing the recommendations , or they relied on lower- quality evidence . The guidelines varied in the studies they reported , weighting of observational or modeling studies relative to r and omized controlled trials ( RCTs ) , and emphasis on relative versus absolute effects . The guidelines rarely addressed the small absolute effect on breast cancer mortality ; the long lead time to any reduction in this mortality , especially in women with estimated life expectancy less than 15 to 20 years ; and the low incidence of breast cancer for women younger than 60 years . Mammography Depending on the guideline , the recommended age to discuss initiating screening is 40 years ( 4 , 5 , 8) and the recommended age to start screening ranges from 40 ( 9 , 10 ) to 45 ( 4 ) to 50 ( 58 ) years . Most guidelines agree to screen average-risk women with  mammography  between ages 50 and 74 years . However , WHO and CTFPHC recommend that screening in women aged 50 to 69 years should include shared decision making because screening is conditional on a woman 's values and preferences . For women aged 70 to 75 years , WHO recommends screening only in the context of both rigorous research and shared decision making . Other areas of disagreement include screening in women aged 40 to 49 years , screening in women aged 75 years or older , and recommended screening intervals ( Table ) . Intervals range from annual ( particularly in women aged 40 to 49 years ) to biennial or triennial . Guidelines from ACS , USPSTF , and WHO conclude that a close balance exists between screening benefits and harms for women in their 40s ( for ACS , 40 to 44 years ) and that decisions are influenced by patient preferences . The WHO guideline suggests population -based screening programs in women aged 40 to 49 years only in the context of rigorous research , monitoring , and evaluation and if shared decision-making strategies are implemented . The CTFPHC conditionally recommends against screening in women aged 40 to 49 years ( without a first-degree family history of breast cancer ) ; however , it states that some women in this age group may wish to be screened and that clinicians should engage in shared decision making with women who express interest ( Appendix ) . Appendix Table 2 summarizes the available data from the 4 guidelines with the highest AGREE II scores ( ACS , CTFPHC , USPSTF , and WHO ) . Appendix Table 2 . Summary of Evidence on Screening : The purpose of this up date of the European Society of Anaesthesiology ( ESA ) guidelines on the pre-operative evaluation of the adult undergoing noncardiac surgery is to present recommendations based on the available relevant clinical evidence . Well performed r and omised studies on the topic are limited and therefore many recommendations rely to a large extent on expert opinion and may need to be adapted specifically to the healthcare systems of individual countries . This article aims to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthesiologists all over Europe to integrate - wherever possible - this knowledge into daily patient care . The Guidelines Committee of the ESA formed a task force comprising members of the previous task force , members of ESA scientific subcommittees and an open call for volunteers was made to all individual active members of the ESA and national societies . Electronic data bases were search ed from July 2010 ( end of the literature search of the previous ESA guidelines on pre-operative evaluation ) to May 2016 without language restrictions . A total of 34 066 abtracts were screened from which 2536 were included for further analysis . Relevant systematic review s with meta-analyses , r and omised controlled trials , cohort studies , case-control studies and cross-sectional surveys were selected . The Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) system was used to assess the level of evidence and to grade recommendations . The final draft guideline was posted on the ESA website for 4 weeks and the link was sent to all ESA members , individual or national ( thus including most European national anaesthesia societies ) . Comments were collated and the guidelines amended as appropriate . When the final draft was complete , the Guidelines Committee and ESA Board ratified the guidelines Anemia result ing from cancer or its treatment is an important clinical problem increasingly treated with the recombinant hematopoietic growth factor erythropoietin . To address uncertainties regarding indications and efficacy , the American Society of Clinical Oncology and the American Society of Hematology developed an evidence -based clinical practice guideline for the use of epoetin in patients with cancer . The guideline panel found good evidence to recommend use of epoetin as a treatment option for patients with chemotherapy-associated anemia with a hemoglobin ( Hgb ) concentration below 10 g/dL. Use of epoetin for patients with less severe anemia ( Hgb level below 12 g/dL but never below 10 g/dL ) should be determined by clinical circumstances . Good evidence from clinical trials supports the use of subcutaneous epoetin thrice weekly ( 150 U/kg ) for a minimum of 4 weeks . Less strong evidence supports an alternative weekly ( 40 000 U/wk ) dosing regimen , based on common clinical practice . With either administration schedule , dose escalation should be considered for those not responding to the initial dose . In the absence of response , continuing epoetin beyond 6 - 8 weeks does not appear to be beneficial . Epoetin should be titrated once the hemoglobin concentration reaches 12 g/dL. Evidence from one r and omized controlled trial supports use of epoetin for patients with anemia associated with low-risk myelodysplasia not receiving chemotherapy ; however , there are no published high- quality studies to support its use for anemia in other hematologic malignancies in the absence of chemotherapy . Therefore , for anemic patients with hematologic malignancies it is recommended that physicians initiate conventional therapy and observe hematologic response before considering use of epoetin Based on clinical assessment alone , patients with stage II non-small cell lung cancer ( NSCLC ) comprise only 5 % of all patients with NSCLC . In addition , patients with stage II NSCLC represent a heterogeneous group , since stage II consists of patients with T1 - 2N1 or T3N0 tumors . By definition , patients with tumor invading the chest wall apex , mediastinum , diaphragm , or even the mainstem bronchus may all have T3 tumors . The extent of the data available regarding treatment of each of these different groups is therefore limited . The quality of the data is limited as well , because information often comes from small series of patients . Studies of adjuvant therapy after complete resection of stage II NSCLC are an important exception to this generalization , since data from large , r and omized studies of adjuvant radiation therapy , chemotherapy , or a combination of the two are available for analysis . Superior sulcus tumors are discussed elsewhere in these guidelines BACKGROUND In 2010 , the Canadian Thoracic Society ( CTS ) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older , and adults , including an up date d Asthma Management Continuum . The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline up date process , focusing , in this first iteration , on topics of controversy and ⁄or gaps in the previous guidelines . METHODS Four clinical questions were identified as a focus for the up date d guideline : the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy ; the initiation of adjunct therapy to inhaled corticosteroids ( ICS ) for uncontrolled asthma ; the role of a single inhaler of an ICS⁄long-acting beta(2)-agonist combination as a reliever , and as a reliever and a controller ; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan . The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics . In addition , literature search es were performed to identify relevant systematic review s and r and omized controlled trials . The panel formally assessed and grade d the evidence , and made 34 recommendations . RESULTS The up date d guideline recommendations outline a role for inclusion of assessment of sputum eosinophils , in addition to st and ard measures of asthma control , to guide adjustment of controller therapy in adults with moderate to severe asthma . Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations . New recommendations for the adjustment of controller medication within written action plans are provided . Finally , priority areas for future research were identified . CONCLUSIONS The present clinical practice guideline is the first up date of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee 's new guideline development process . Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide up date s reflecting new evidence PURPOSE This report up date s the Cancer Care Ontario Program in Evidence -Based Care guideline for the management of  depression in adult patients with cancer . This guideline covers pharmacologic , psychological , and collaborative care interventions , with a focus on integrating practical management tools to assist clinicians in delivering appropriate treatments for depression in patients with cancer . METHODS Recommendations were developed by synthesizing information from extant guidelines and review s and search ing for r and omized controlled trials from the date of data base inception ( 1964 for MEDLINE and 1974 for EMBASE ) to January 2015 . Quality assessment of guidelines and systematic review s were conducted by using the Appraisal of Guidelines for Research and Evaluation II ( AGREE II ) , Assessment of Multiple Systematic Review s ( AMSTAR ) , and Cochrane Risk of Bias tools . Final recommendations were developed through a st and ardized Program in Evidence -Based Care multidisciplinary expert and knowledge user review process . RESULTS Two high- quality relevant clinical practice guidelines , eight pharmacologic trials , nine psychological trials , and eight collaborative care intervention trials composed the evidence base upon which the recommendations were developed . Eight specific recommendations were made to establish a st and ard of care for the management of depression in patients with cancer . The recommendations and practical management tools were review ed as being well organized and helpful , although systemic barriers to implementation were identified . CONCLUSION This up date d guideline supports the previous general recommendation that patients with cancer who have depression may benefit from psychological and /or pharmacologic interventions , without evidence for the superiority of any specific treatment over another . New recommendations for a collaborative care model that incorporates a stepped care approach suggest that multidisciplinary mental health care restructuring may be required for optimal management of depression GUIDELINE QUESTIONS 1 ) Does G-CSF reduce the incidence of important adverse clinical outcomes due to infections in patients with cancer treated with myelosuppressive therapy ? 2 ) Does G-CSF allow maintenance of the chemotherapy dose with the goal of improving survival ? OBJECTIVE To evaluate the evidence for the role of G-CSF in patients receiving myelosuppressive chemotherapy for the treatment of cancer . OUTCOMES Clinical outcomes reflecting events that may affect quality of life and /or re source utilization ( e.g. , rates and duration of hospitalization , antibiotic use ) ; outcomes reflecting the effect of treatment on infection rates , tumour response and survival and those related to the biological effect of G-CSF . PERSPECTIVE ( VALUES ) Evidence was selected , review ed and synthesized by members of the Provincial Systemic Treatment Disease Site Group ( DSG ) of the Cancer Care Ontario Practice Guidelines Initiative . Drafts of this document have been circulated and review ed by members of the Systemic Treatment DSG . The DSG comprises medical oncologists , pharmacists , supportive care personnel and administrators . Evaluation by clinicians was considered in the final practice guideline . Community representatives did not participate in the development of this report but will in future reports . Guidelines approval does require participation by community representatives . QUALITY OF EVIDENCE Two published guidelines and an up date of one guideline were identified . Ten eligible r and omized controlled trials published in English were included . BENEFITS A meta- analysis of data from 8 trials showed that the odds of experiencing febrile neutropenia with G-CSF were significantly reduced ( odds ratio 0.38 ; 95 % confidence interval [ CI ] 0.27 to 0.52 ; p < 0.00001 ) . G-CSF reduced the risk of febrile neutropenia by 34 % ( risk ratio 0.66 ; 95 % CI 0.51 to 0.86 ; p = 0.0015 ) . The use of G-CSF was associated with a significant reduction in antibiotic usage and days spent in hospital in 2 trials and had no effect in the other 4 in which it was measured . Five trials reported no difference in overall median survival , with 2 small trials detecting a significant increase related to G-CSF . However , further research is necessary to confirm these results . HARMS The toxic effects of G-CSF are relatively mild . The most consistent clinical symptom attributed to G-CSF is bone pain , reported in incidence rates ranging from 20 % to 50 % in 3 trials . Except for one case , reported bone pain was mild . PRACTICE GUIDELINE In cancer patients receiving myelosuppressive chemotherapy , granulocyte colony-stimulating factor ( G-CSF ) may be beneficial for some patients . If a reduction in the number of febrile neutropenic episodes , or in the duration of such episodes , is expected to improve quality of life , then G-CSF is a reasonable treatment option for selected patients . A clear justification for the use of G-CSF should be stated . If the objective of using G-CSF is to maintain dose intensity of antitumour agents , then G-CSF can be recommended where reduction in dose intensity has been shown in r and omized controlled trials to reduce survival or disease-free survival . Although the evidence is weaker , the Systemic Treatment DSG would support the practice endorsed by other guidelines ( American Society of Clinical Oncology , Ontario Drug Benefit Plan ) and would recommend G-CSF for patients receiving potentially curative chemotherapy : i ) as primary prophylaxis ; that is , where dose reductions below a specified level are required because of a known high risk of febrile neutropenia , or ii ) as secondary prophylaxis in patients receiving chemotherapy of established efficacy who have suffered a prior serious episode of febrile neutropenia due to the same chemotherapy regimen . The exact cut-off for dose reductions is unknown at this time and ought to be left to the judgement of the clinician . In general , the use of  G-CSF  for dose reductions lower than 20 % is not recommended . ( ABSTRACT TRUNCATED OBJECTIVE The aim was to formulate practice guidelines on the management of  hyperglycemia in hospitalized patients in the non-critical care setting . PARTICIPANTS The Task Force was composed of a chair , selected by the Clinical Guidelines Subcommittee of The Endocrine Society , six additional experts , and a method ologist . EVIDENCE This evidence -based guideline was developed using the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) system to describe both the strength of recommendations and the quality of evidence . CONSENSUS PROCESS One group meeting , several conference calls , and e-mail communications enabled consensus . Endocrine Society members , American Diabetes Association , American Heart Association , American Association of Diabetes Educators , European Society of Endocrinology , and the Society of Hospital Medicine review ed and commented on preliminary drafts of this guideline . CONCLUSIONS Hyperglycemia is a common , serious , and costly health care problem in hospitalized patients . Observational and r and omized controlled studies indicate that improvement in glycemic control results in lower rates of hospital complications in general medicine and surgery patients . Implementing a st and ardized sc insulin order set promoting the use of scheduled basal and nutritional insulin therapy is a key intervention in the inpatient management of diabetes . We provide recommendations for practical , achievable , and safe glycemic targets and describe protocol s , procedures , and system improvements required to facilitate the achievement of glycemic goals in patients with hyperglycemia and diabetes admitted in non-critical care setting PURPOSE To develop a guideline for the use of sentinel node biopsy ( SNB ) in early stage breast cancer . METHODS An American Society of Clinical Oncology ( ASCO ) Expert Panel conducted a systematic review of the literature available through February 2004 on the use of SNB in early-stage breast cancer . The panel developed a guideline for clinicians and patients regarding the appropriate use of a sentinel lymph node identification and sampling procedure from hereon referred to as SNB . The guideline was review ed by selected experts in the field and the ASCO Health Services Committee and was approved by the ASCO Board of Directors . RESULTS The literature review identified one published prospect i ve r and omized controlled trial in which SNB was compared with axillary lymph node dissection ( ALND ) , four limited meta-analyses , and 69 published single-institution and multicenter trials in which the test performance of SNB was evaluated with respect to the results of ALND ( completion axillary dissection ) . There are currently no data on the effect of SLN biopsy on long-term survival of patients with breast cancer . However , a review of the available evidence demonstrates that , when performed by experienced clinicians , SNB appears to be a safe and acceptably accurate method for identifying early-stage breast cancer without involvement of the axillary lymph nodes . CONCLUSION SNB is an appropriate initial alternative to routine staging ALND for patients with early-stage breast cancer with clinical ly negative axillary nodes . Completion ALND remains st and ard treatment for patients with axillary metastases identified on SNB . Appropriately identified patients with negative results of SNB , when done under the direction of an experienced surgeon , need not have completion ALND . Isolated cancer cells detected by pathologic examination of the SLN with use of specialized techniques are currently of unknown clinical significance . Although such specialized techniques are often used , they are not a required part of SLN evaluation for breast cancer at this time . Data suggest that SNB is associated with less morbidity than ALND , but the comparative effects of these two approaches on tumor recurrence or patient survival are unknown PURPOSE To develop an evidence -based guideline on central venous catheter ( CVC ) care for patients with cancer that addresses catheter type , insertion site , and placement as well as prophylaxis and management of both catheter-related infection and thrombosis . METHODS A systematic search of MEDLINE and the Cochrane Library ( 1980 to July 2012 ) identified relevant articles published in English . RESULTS The overall quality of the r and omized controlled trial evidence was rated as good . There is consistency among meta-analyses and guidelines compiled by other groups as well . RECOMMENDATIONS There is insufficient evidence to recommend one CVC type or insertion site ; femoral catheterization should be avoided . CVC should be placed by well-trained providers , and the use of a CVC clinical care bundle is recommended . The use of antimicrobial/antiseptic-impregnated and /or heparin-impregnated CVCs is recommended to decrease the risk of catheter-related infections for short-term CVCs , particularly in high-risk groups ; more research is needed . The prophylactic use of systemic antibiotics is not recommended before insertion . Data are not sufficient to recommend for or against routine use of antibiotic flush/lock therapy ; more research is needed . Before starting antibiotic therapy , cultures should be obtained . Some life-threatening infections require immediate catheter removal , but most can be treated with antimicrobial therapy while the CVC remains in place . Routine flushing with saline is recommended . Prophylactic use of warfarin or low-molecular weight heparin is not recommended , although a tissue plasminogen activator ( t-PA ) is recommended to restore patency to occluded catheters . CVC removal is recommended when the catheter is no longer needed or if there is a radiologically confirmed thrombosis that worsens despite anticoagulation therapy PURPOSE To up date the 1999 American Society of Clinical Oncology ( ASCO ) guideline on breast cancer follow-up and management in the adjuvant setting . METHODS An ASCO Expert Panel review ed pertinent information from the literature through March 2006 . More weight was given to studies that tested a hypothesis directly relating testing to one of the primary outcomes in a r and omized design . RESULTS The evidence supports regular history , physical examination , and mammography as the cornerstone of appropriate breast cancer follow-up . All patients should have a careful history and physical examination performed by a physician experienced in the surveillance of cancer patients and in breast examination . Examinations should be performed every 3 to 6 months for the first 3 years , every 6 to 12 months for years 4 and 5 , and annually thereafter . For those who have undergone breast-conserving surgery , a post-treatment mammogram should be obtained 1 year after the initial mammogram and at least 6 months after completion of radiation therapy . Thereafter , unless otherwise indicated , a yearly mammographic evaluation should be performed . Patients at high risk for familial breast cancer syndromes should be referred for genetic counseling . The use of CBCs , chemistry panels , bone scans , chest radiographs , liver ultrasounds , computed tomography scans , [18F]fluorodeoxyglucose-positron emission tomography scanning , magnetic resonance imaging , or tumor markers ( carcinoembryonic antigen , CA 15 - 3 , and CA 27.29 ) is not recommended for routine breast cancer follow-up in an otherwise asymptomatic patient with no specific findings on clinical examination . CONCLUSION Careful history taking , physical examination , and regular mammography are recommended for appropriate detection of breast cancer recurrence INTRODUCTION Accurate staging of lymph node involvement is a critical aspect of the initial management of nonmetastatic non-small cell lung cancer ( NSCLC ) . We sought to determine whether the current N descriptors should be maintained or revised for the next edition of the international lung cancer staging system . METHODS A retrospective international lung cancer data base was developed and analyzed . Anatomical location of lymph node involvement was defined by the Naruke ( for Japanese data ) and American Thoracic Society ( for non-Japanese data ) nodal maps . Survival was calculated by the Kaplan-Meier method , and prognostic groups were assessed by Cox regression analysis . RESULTS Current N0 to N3 descriptors defined distinct prognostic groups for both clinical and pathologic staging . Exploratory analyses indicated that lymph node stations could be grouped together into six " zones " : peripheral or hilar for N1 , and upper or lower mediastinal , aortopulmonary , and subcarinal for N2 nodes . Among patients undergoing resection without induction therapy  , there were three distinct prognostic groups : single-zone N1 , multiple-zone N1 or single N2 , and multiple-zone N2 disease . Nevertheless , there were insufficient data to determine whether the N descriptors should be subdivided ( e.g. , N1a , N1b , N2a , N2b ) . CONCLUSIONS Current N descriptors should be maintained in the NSCLC staging system . Prospect i ve studies are needed to vali date amalgamating lymph node stations into zones and subdividing N descriptors A.S.P.E.N. and SCCM are both nonprofit organizations composed of multidisciplinary healthcare professionals . The mission of A.S.P.E.N. is to improve patient care by advancing the science and practice of clinical nutrition and metabolism . The mission of SCCM is to secure the highest quality care for all critically ill and injured patients . Guideline Limitations : These A.S.P.E.N.−SCCM Clinical Guidelines are based on general conclusions of health professionals who , in developing such guidelines , have balanced potential benefits to be derived from a particular mode of medical therapy against certain risks inherent with such therapy . However , practice guidelines are not intended as absolute requirements . The use of these practice guidelines does not in any way project or guarantee any specific benefit in outcome or survival . The judgment of the healthcare professional based on individual circumstances of the patient must always take precedence over the recommendations in these guidelines . The guidelines offer basic recommendations that are supported by review and analysis of the current literature , other national and international guidelines , and a blend of expert opinion and clinical practicality . The population of critically ill patients in an intensive care unit ( ICU ) is not homogeneous . Many of the studies on which the guidelines are based are limited by sample size , patient heterogeneity , variability in disease severity , lack of baseline nutritional status , and insufficient statistical power for analysis . Periodic Guideline Review and Up date : This particular report is an up date and expansion of guidelines published by A.S.P.E.N. and SCCM in 2009 ( 1 ) . Governing bodies of both A.S.P.E.N. and SCCM have m and ated that these guidelines be up date d every three to five years . The data base of r and omized controlled trials ( RCTs ) that served as the platform for the analysis of the literature was assembled in a joint “ harmonization process ” with the Canadian Clinical Guidelines group . Once completed , each group operated separately in their interpretation of the studies and derivation of guideline recommendations ( 2 ) . The current A.S.P.E.N. and SCCM guidelines included in this paper were derived from data obtained via literature search es by the authors through December 31 , 2013 . Although the committee was aware of l and mark studies published after this date , these data were not included in this manuscript . The process by which the literature was evaluated necessitated a common end date for the search review . Adding a last-minute l and mark trial would have introduced bias unless a formalized literature search was re-conducted for all sections of the manuscript . Target Patient Population for Guideline : The target of these guidelines is intended to be the adult ( ≥ 18 years ) critically ill patient expected to require a length of stay ( LOS ) greater than 2 or 3 days in a medical ICU ( MICU ) or surgical ICU ( SICU ) . The current guidelines were exp and ed to include a number of additional subsets of patients who met the above criteria , but were not included in the previous 2009 guidelines . Specific patient population s addressed by these exp and ed and up date d guidelines include organ failure ( pulmonary , renal , and liver ) , acute pancreatitis , surgical subsets ( trauma , traumatic brain injury [ TBI ] , open abdomen [ OA ] , and burns ) , sepsis , postoperative major surgery , chronic critically ill , and critically ill obese . These guidelines are directed toward generalized patient population s but , like any other management strategy in the ICU , nutrition therapy should be tailored to the individual patient . Target Audience : The intended use of these guidelines is for all healthcare providers involved in nutrition therapy of the critically ill , primarily physicians , nurses , dietitians , and pharmacists . Methodology : The authors compiled clinical questions reflecting key management issues in nutrition therapy . A committee of multidisciplinary experts in clinical nutrition composed of physicians , nurses , pharmacists , and dietitians was jointly convened by the two societies PURPOSE To up date the 1999 American Society of Clinical Oncology guideline for antiemetics in oncology . UP DATE METHODOLOGY The Up date Committee completed a review and analysis of data published from 1998 thru February 2006 . The literature review focused on published r and omized controlled trials , and systematic review s and meta-analyses of published phase II and phase III r and omized controlled trials . RECOMMENDATIONS The three-drug combination of a 5-hydroxytryptamine-3 ( 5-HT(3 ) ) serotonin receptor antagonist , dexamethasone , and aprepitant is recommended before chemotherapy of high emetic risk . For persons receiving chemotherapy of high emetic risk , there is no group of patients for whom agents of lower therapeutic index are appropriate first-choice antiemetics . These agents should be reserved for patients intolerant of or refractory to 5-HT3 serotonin receptor antagonists , neurokinin-1 receptor antagonists , and dexamethasone . The three-drug combination of a 5-HT3 receptor serotonin antagonist , dexamethasone , and aprepitant is recommended for patients receiving an anthracycline and cyclophosphamide . For patients receiving other chemotherapy of moderate emetic risk , the Up date Committee continues to recommend the two-drug combination of a 5-HT3 receptor serotonin antagonist and dexamethasone . In all patients receiving cisplatin and all other agents of high emetic risk , the two-drug combination of dexamethasone and aprepitant is recommended for the prevention of delayed emesis . The Up date Committee no longer recommends the combination of a 5-HT3 serotonin receptor antagonist and dexamethasone for the prevention of delayed emesis after chemotherapeutic agents of high emetic risk . CONCLUSION The Up date Committee recommends that clinicians administer antiemetics while considering patients ' emetic risk categories and other characteristics d t m n d m e D m This is one of a series of statements discussing the use of GI endoscopy in common clinical situations . The St and ards of Practice Committee of the American Society for Gastrointestinal Endoscopy ( ASGE ) prepared this text . This guideline is an up date of a previous ASGE guideline published in 2005.1 In preparing this guideline , a search of the medical literature was performed by using PubMed . Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants . When few or no data exist from well- design ed prospect i ve trials , emphasis is given to results from large series and reports from recognized experts . Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time that the guidelines are drafted . Further controlled clinical studies may be needed to clarify aspects of this guideline . This guideline may be revised as necessary to account for changes in technology , new data , or other aspects of clinical practice . The recommendations are based on review ed studies and are grade d on the strength of the supporting evidence ( Table 1).2 The trength of individual recommendations is based on both he aggregate evidence quality and an assessment of the nticipated benefits and harms . Weaker recommendaions are indicated by phrases such as “ We suggest , ” hereas stronger recommendations are typically stated as We recommend . ” This guideline is intended to be an educational device o provide information that may assist endoscopists in roviding care to patients . This guideline is not a rule and hould not be construed as establishing a legal st and ard of are or as encouraging , advocating , requiring , or discourging any particular treatment . Clinical decisions in any articular case involve a complex analysis of the patient ’s ondition and available courses of action . Therefore , clincal considerations may lead an endoscopist to take a ourse of action that varies from these guidelines Purpose To increase awareness , outline strategies , and offer guidance on the recommended management of immune-related adverse events in patients treated with immune checkpoint inhibitor ( ICPi ) therapy .  Methods A multidisciplinary , multi-organizational panel of experts in medical oncology , dermatology , gastroenterology , rheumatology , pulmonology , endocrinology , urology , neurology , hematology , emergency medicine , nursing , trialist , and advocacy was convened to develop the clinical practice guideline . Guideline development involved a systematic review of the literature and an informal consensus process . The systematic review focused on guidelines , systematic review s and meta-analyses , r and omized controlled trials , and case series published from 2000 through 2017 . Results The systematic review identified 204 eligible publications . Much of the evidence consisted of systematic review s of observational data , consensus guidelines , case series , and case reports . Due to the paucity of high- quality evidence on management of immune-related adverse events , recommendations are based on expert consensus . Recommendations Recommendations for specific organ system-based toxicity diagnosis and management are presented . While management varies according to organ system affected , in general , ICPi therapy should be continued with close monitoring for grade 1 toxicities , with the exception of some neurologic , hematologic , and cardiac toxicities .  ICPi therapy may be suspended for most grade 2 toxicities , with consideration of resuming when symptoms revert to grade 1 or less . Corticosteroids may be administered . Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids ( prednisone 1 to 2 mg/kg/d or methylprednisolone 1 to 2 mg/kg/d ) . Corticosteroids should be tapered over the course of at least 4 to 6 weeks . Some refractory cases may require infliximab or other immunosuppressive therapy . In general , permanent discontinuation of ICPis is recommended with grade 4 toxicities , with the exception of endocrinopathies that have been controlled by hormone replacement . Additional information is available at www.asco.org/supportive-care- guidelines and www.asco.org/ guidelines wiki PURPOSE An American Society of Clinical Oncology ( ASCO ) provisional clinical opinion ( PCO ) offers timely clinical direction to ASCO 's membership following publication or presentation of potentially practice -changing data from major studies . This PCO addresses the integration of palliative care services into st and ard oncology practice at the time a person is diagnosed with metastatic or advanced cancer . CLINICAL CONTEXT Palliative care is frequently misconstrued as synonymous with end-of-life care . Palliative care is focused on the relief of suffering , in all of its dimensions , throughout the course of a patient 's illness . Although the use of hospice and other palliative care services at the end of life has increased , many patients are enrolled in hospice less than 3 weeks before their death , which limits the benefit they may gain from these services . By potentially improving quality of life ( QOL ) , cost of care , and even survival in patients with metastatic cancer , palliative care has increasing relevance for the care of patients with cancer . Until recently , data from r and omized controlled trials ( RCTs ) demonstrating the benefits of palliative care in patients with metastatic cancer who are also receiving st and ard oncology care have not been available . RECENT DATA Seven published RCTs form the basis of this PCO . PROVISIONAL CLINICAL OPINION Based on strong evidence from a phase III RCT , patients with metastatic non-small-cell lung cancer should be offered concurrent palliative care and st and ard oncologic care at initial diagnosis . While a survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology setting s , substantial evidence demonstrates that palliative care-when combined with st and ard cancer care or as the main focus of care-leads to better patient and caregiver outcomes . These include improvement in symptoms , QOL , and patient satisfaction , with reduced caregiver burden . Earlier involvement of palliative care also leads to more appropriate referral to and use of hospice , and reduced use of futile intensive care . While evidence clarifying optimal delivery of palliative care to improve patient outcomes is evolving , no trials to date have demonstrated harm to patients and caregivers , or excessive costs , from early involvement of palliative care . Therefore , it is the Panel 's expert consensus that combined st and ard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and /or high symptom burden . Strategies to optimize concurrent palliative care and st and ard oncology care , with evaluation of its impact on important patient and caregiver outcomes ( eg , QOL , survival , health care services utilization , and costs ) and on society , should be an area of intense research . NOTE ASCO 's provisional clinical opinions ( PCOs ) reflect expert consensus based on clinical evidence and literature available at the time they are written and are intended to assist physicians in clinical decision making and identify questions and setting s for further research . Because of the rapid flow of scientific information in oncology , new evidence may have emerged since the time a PCO was su bmi tted for publication . PCOs are not continually up date d and may not reflect the most recent evidence . PCOs can not account for individual variation among patients and can not be considered inclusive of all proper methods of care or exclusive of other treatments . It is the responsibility of the treating physician or other health care provider , relying on independent experience and knowledge of the patient , to determine the best course of treatment for the patient . Accordingly , adherence to any PCO is voluntary , with the ultimate determination regarding its application to be made by the physician in light of each patient 's individual circumstances . ASCO PCOs describe the use of procedures and therapies in clinical trials and can not be assumed to apply to the use of these interventions in the context of clinical practice . ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of ASCO 's PCOs , or for any errors or omissions Purpose Cardiac dysfunction is a serious adverse effect of certain cancer-directed therapies that can interfere with the efficacy of treatment , decrease quality of life , or impact the actual survival of the patient with cancer . The purpose of this effort was to develop recommendations for prevention and monitoring of cardiac dysfunction in survivors of adult-onset cancers . Methods Recommendations were developed by an expert panel with multidisciplinary representation using a systematic review ( 1996 to 2016 ) of meta-analyses , r and omized clinical trials , observational studies , and clinical experience . Study quality was assessed using established methods , per study design . The guideline recommendations were crafted in part using the Guidelines Into Decision Support methodology . Results A total of 104 studies met eligibility criteria and compose the evidentiary basis for the recommendations . The strength of the recommendations in these guidelines is based on the quality , amount , and consistency of the evidence and the balance between benefits and harms . Recommendations It is important for health care providers to initiate the discussion regarding the potential for cardiac dysfunction in individuals in whom the risk is sufficiently high before beginning therapy . Certain higher risk population s of survivors of cancer may benefit from prevention and screening strategies implemented during cancer-directed therapies . Clinical suspicion for cardiac disease should be high and threshold for cardiac evaluation should be low in any survivor who has received potentially cardiotoxic therapy . For certain higher risk survivors of cancer , routine surveillance with cardiac imaging may be warranted after completion of cancer-directed therapy , so that appropriate interventions can be initiated to halt or even reverse the progression of cardiac dysfunction BACKGROUND The purpose of this statement is to up date the recommendations by the American Heart Association ( AHA ) for the prevention of infective endocarditis that were last published in 1997 . METHODS AND RESULTS A writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis , with liaison members representing the American Dental Association , the Infectious Diseases Society of America , and the American Academy of Pediatrics . The writing group review ed input from national and international experts on infective endocarditis . The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective endocarditis , in vitro susceptibility data of the most common microorganisms that cause infective endocarditis , results of prophylactic studies in animal models of experimental endocarditis , and retrospective and prospect i ve studies of prevention of infective endocarditis . MEDLINE data base search es from 1950 to 2006 were done for English- language papers using the following search terms : endocarditis , infective endocarditis , prophylaxis , prevention , antibiotic , antimicrobial , pathogens , organisms , dental , gastrointestinal , genitourinary , streptococcus , enterococcus , staphylococcus , respiratory , dental surgery , pathogenesis , vaccine , immunization , and bacteremia . The reference lists of the identified papers were also search ed . We also search ed the AHA online library . The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used . The paper was subsequently review ed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee . CONCLUSIONS The major changes in the up date d recommendations include the following : ( 1 ) The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 % effective . ( 2 ) Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis . ( 3 ) For patients with these underlying cardiac conditions , prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa . ( 4 ) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis . ( 5 ) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure . These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations PURPOSE To identify optimal chemo- and targeted therapy for women with human epidermal growth factor 2 (HER2)- negative ( or unknown ) advanced breast cancer . METHODS A systematic review of r and omized evidence ( including systematic review s and meta-analyses ) from 1993 through to current was completed . Outcomes of interest included survival , progression-free survival , response , quality of life , and adverse effects . Guideline recommendations were evidence based and were agreed on by the Expert Panel via consensus . RESULTS Seventy-nine studies met the inclusion criteria , comprising 20 systematic review s and /or meta-analyses , 30 trials on first-line treatment , and 29 trials on second-line and subsequent treatment . These trials form the evidence base for the guideline recommendations . RECOMMENDATIONS Endocrine therapy is preferable to chemotherapy as first-line treatment for patients with estrogen receptor-positive metastatic breast cancer unless improvement is medically necessary ( eg , immediately life-threatening disease ) . Single agent is preferable to combination chemotherapy , and longer planned duration improves outcome but must be balanced against toxicity . There is no single optimal first-line or subsequent line chemotherapy , and choice of treatment will be determined by multiple factors including prior therapy , toxicity , performance status , comorbid conditions , and patient preference . The role of bevacizumab remains controversial . Other targeted therapies have not so far been shown to enhance chemotherapy outcome in HER2-negative breast cancer After more than three decades of clinical trials testing various st and ard-dose chemotherapy regimens , the disease course of patients with multiple myeloma has not changed appreciably . Conventional chemotherapy can provide effective palliation but is not curative ( 1 ) . Case series have described encouraging results in patients with myeloma undergoing allogeneic or autologous bone marrow or peripheral blood stem-cell transplantation ( 2 ) . Other studies of transplantation , including r and omized trials , have been reported in the past 6 years ( 3 , 4 ) . To facilitate decisions about treatment options , practice guidelines have been developed for use by health care providers and consumers . In Ontario , Canada , cancer treatments and policies are led by a state-funded organization , Cancer Care Ontario . To help derive treatment options , Cancer Care Ontario has developed the Program in Evidence -Based Care , which includes the Practice Guidelines Initiative . Disease Site Groups ( DSGs ) , which comprise physicians , epidemiologists , and consumers , develop guidelines through a systematic process that involves assessment of evidence , consensus , and a validation process involving practitioners from across the province . Guideline topics are chosen through a prioritization process that includes the burden of illness , availability of evidence , perceived variation in practice , the potential to affect treatment decisions , and re source utilization . The Hematology DSG noted that the use of transplantation for patients with myeloma varied among practice s across the province . Variability in practice and emerging evidence of higher quality made this a priority topic for guideline development . To approach this topic , the DSG addressed the following questions : What is optimal st and ard-dose chemotherapy for patients with myeloma ? In terms of survival , is  peripheral blood stem-cell  or  marrow transplantation better than conventional chemotherapy ? What is the relative efficacy of autologous versus allogeneic transplantation ? What specifics of the transplantation process can be recommended ? When should transplantation be performed ? Who should ( or should not ) receive a transplant ? Methods Overview of Guideline Development This guideline was developed by the Cancer Care Ontario Practice Guidelines Initiative ( CCOPGI ) using the methods of the Practice Guidelines Development Cycle ( 5 ) . Members of the CCOPGI 's Hematology DSG selected , review ed , and interpreted the evidence . This DSG comprises 25 members , including hematologists , medical and radiation oncologists , an epidemiologist , and 2 lay representatives . Several of the physician members have background training in epidemiology ; 8 hematologists regularly perform stem-cell transplantation in clinical practice . The DSG 's draft recommendations were circulated through a mailed survey to hematologists and medical or radiation oncologists in Ontario for feedback and involvement in a consensus process . Responses were used to guide the reformatting of the draft into the final guideline recommendations . The Practice Guidelines Co-ordinating Committee ( PGCC ) , which ensures consistency of guideline development across the DSGs of various tumor sites , approved the guideline . The CCOPGI has a st and ardized process to up date each guideline report ; the current guideline was up date d and review ed by the PGCC in October 2000 . Literature Search Strategy We search ed the MEDLINE , CANCERLIT , and Cochrane Library data bases for literature published from 1992 to December 1997 and subsequently up date d the search in October 1998 , June 1999 , and April 2000 . For the search es , we combined multiple myeloma ( as a Medical Subject Heading [ MeSH ] and text word ) with bone marrow transplantation ( MeSH and text word ) and drug therapy ( MeSH ) . Then , we combined these terms with the search terms for the following study design s : practice guidelines ; systematic review s or meta-analyses ; review s ; r and omized , controlled trials ; controlled clinical trials ; and comparative studies . In addition , we search ed the PubMed and Physician Data Query ( PDQ ) ( www.cancer.gov/ search / clinical _ trials/ ) data bases and review ed relevant conference proceedings ( American Society of Hematology , 1997 to 1999 , and American Society of Clinical Oncology , 1999 to 2000 ) , article bibliographies , and personal files . To address the issue of optimal chemotherapy , we performed an additional search of the same data bases using the term multiple myeloma ( MeSH ) combined with r and omized , controlled trials ( MeSH ) and the text word r and om in the title . Inclusion Criteria We selected study reports meeting one of the three following criteria : r and omized trial or meta- analysis of therapy for patients with myeloma that reported survival or quality -of-life outcomes ; nonr and omized comparative trial that addressed transplantation strategy , including a contemporaneous control group , and that reported survival or quality -of-life outcomes ; or economic evaluation that addressed transplantation strategy . Because of insufficient data on the specifics of the transplantation process and the patients who would be most likely to benefit from transplantation , we performed a second search , which identified data from noncomparative case-series studies . Data Extraction and Interpretative Summary Three members of the DSG , including an epidemiologist , determined eligibility of the articles and abstract s obtained from the literature search . The lead DSG member for this guideline extracted and summarized relevant data according to the guideline question addressed . The DSG members then review ed the summarized data and key articles . The DSG met formally three to four times annually ; at these meetings , the members method ologically assessed the articles , interpreted the data , and debated specific points in an attempt to reach a consensus . Synthesizing the Evidence Because all of the nine r and omized trials on transplantation addressed different questions , we did not statistically pool the data . DSG Consensus Process Through an iterative process that included debate at formal meetings and circulation of draft recommendations , we considered the implication s of the appraised data for each guideline question . With this process , attempts were made to reach consensus ; when this was impossible , minority opinions were recorded . Approval by each member of the DSG was required before circulation of the draft version for practitioner feedback and su bmi ssion of the final guideline to the PGCC . Practitioner Feedback To obtain practitioner feedback , we mailed a survey to 211 practitioners in Ontario ( 94 hematologists , 93 medical oncologists , and 24 radiation oncologists ) . The survey consisted of st and ardized items asking the practitioner to rate the quality of each draft guideline and to judge whether the draft recommendations should serve as a practice guideline . Written comments were invited . Follow-up reminders were sent at 2 weeks ( by postcard ) and 4 weeks ( entire package ) . After exclusion of 18 retired practitioners , 137 of 193 practitioners ( 71 % ) responded ; 90 of 137 respondents ( 66 % ) indicated that the guideline was relevant to their practice . Approval of the draft guideline was strong among these 90 practitioners : 91 % agreed or strongly agreed that the summary of the evidence was acceptable , 87 % agreed with the draft recommendations , and 81 % approved of the recommendations as a practice guideline . Thirty-nine respondents provided written comments ; these comments were , like the other responses , incorporated in the final guideline . Results Sixty-six reports met the criteria for inclusion and are categorized in Table 1 . In each section below , we describe the studies , summarize results , and describe the guideline development . Table 1 . Evidence Included in This Practice Guideline Report What Is Optimal St and ard-Dose Chemotherapy  for Patients with Multiple Myeloma ? To properly compare transplantation with conventional chemotherapy , we must define optimal conventional chemotherapy . We identified 30 r and omized trials comparing therapies in previously untreated patients . Four meta-analyses ( 6 - 9 ) evaluated these data . The Myeloma Trialists ' Collaborative Group ( 7 ) compared combination chemotherapy with melphalan plus prednisone in a meta- analysis of 27 trials . Twenty of these trials supplied individual-patient data . No difference in survival was detected . The proportional reduction in the annual odds of death was 1.5 % in favor of combination chemotherapy ( 95 % CI , 8 % to 5 % ; P > 0.2 ) , with an odds ratio ( OR ) of 0.99 ( CI , 0.93 to 1.05 ) . An earlier literature -based meta- analysis ( 6 ) of 18 trials also failed to detect a survival difference between groups ( OR , 1.04 [ CI , 0.90 to 1.19 ] ; P > 0.2 ) . Two meta-analyses evaluated interferon for multiple myeloma . An overview of 24 r and omized trials published in abstract form ( 8) demonstrated that interferon improved recurrence-free survival by 6 months and improved 3-year overall survival by 4 % . Another meta- analysis ( 9 ) measured survival by a unique measure called the mean lifetime survival . This meta- analysis found no difference in survival rate between the group receiving interferon and the group not receiving interferon ( 3.9 vs. 3.4 years , respectively ; P = 0.095 ) . Guideline Recommendation Multiagent chemotherapy or melphalan plus prednisone is appropriate therapy for a control group in a comparison of transplantation versus st and ard-dose therapy . The addition of interferon is unlikely to influence outcomes in the control group . In Terms of Survival , Is Autologous Peripheral Blood Stem-Cell or Bone Marrow Transplantation Better than Conventional Chemotherapy ? We review ed two r and omized and three nonr and omized comparisons ( Table 2 ) . Attal and colleagues ( 3 ) r and omly assigned 200 previously untreated patients younger than 65 years of age with stage II or III ( 40 ) myeloma to conventional chemotherapy or to a strategy that included autologous bone marrow transplantation . Patients were r and omly Description This guideline up date s the 2008 American College of Physicians ( ACP ) recommendations on treatment of low bone density and osteoporosis to prevent fractures in men and women . This guideline is endorsed by the American Academy of Family Physicians . Methods The ACP Clinical Guidelines Committee based these recommendations on a systematic review of r and omized controlled trials ; systematic review s ; large observational studies ( for adverse events ) ; and case reports ( for rare events ) that were published between 2 January 2005 and 3 June 2011 . The review was up date d to July 2016 by using a machine-learning method , and a limited up date to October 2016 was done . Clinical outcomes evaluated were fractures and adverse events . This guideline focuses on the comparative benefits and risks of short- and long-term pharmacologic treatments for low bone density , including pharmaceutical prescriptions , calcium , vitamin D , and estrogen . Evidence was grade d according to the GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) system . Target Audience and Patient Population The target audience for this guideline includes all clinicians . The target patient population includes men and women with low bone density and osteoporosis . Recommendation 1 ACP recommends that clinicians offer pharmacologic treatment with alendronate , risedronate , zoledronic acid , or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis . ( Grade : strong recommendation ; high- quality evidence ) . Recommendation 2 ACP recommends that clinicians treat osteoporotic women with pharmacologic therapy for 5 years . ( Grade : weak recommendation ; low- quality evidence ) . Recommendation 3 ACP recommends that clinicians offer pharmacologic treatment with bisphosphonates to reduce the risk for vertebral fracture in men who have clinical ly recognized osteoporosis . ( Grade : weak recommendation ; low- quality evidence ) . Recommendation 4 ACP recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women . ( Grade : weak recommendation ; low- quality evidence ) . Recommendation 5 ACP recommends against using menopausal estrogen therapy or menopausal estrogen plus progestogen therapy or raloxifene for the treatment of osteoporosis in women . ( Grade : strong recommendation ; moderate- quality evidence ) . Recommendation 6 ACP recommends that clinicians should make the decision whether to treat osteopenic women 65 years of age or older who are at a high risk for fracture based on a discussion of patient preferences , fracture risk profile , and benefits , harms , and costs of medications . ( Grade : weak recommendation ; low- quality evidence ) Introduction : Traditional tumor-based staging systems provide limited information on the best treatment option for individual patients with advanced inoperable non-small cell lung cancer ( NSCLC ) . The Glasgow prognostic score ( GPS ) reflects the host systemic inflammatory response and is a vali date d independent prognostic factor in these patients . The aim of this study was to examine the clinical application of the pretreatment GPS in a mature cohort of patients with inoperable NSCLC . Methods : The data of 261 patients with inoperable NSCLC were collected prospect ively and before treatment . Information on patient demographics , body mass index , performance status ( PS ) , the modified Glasgow prognostic score ( mGPS ) , the prognostic index , and treatment received were included . Results : The majority of patients were aged 65 years or older ( 68 % ) , were men ( 59 % ) , had a body mass index more than 20 ( 89 % ) , and an Eastern Cooperative Oncology Group performance status ( ECOG-PS ) 0 or 1 ( 54 % ) . Most patients had a pretreatment mGPS = 1 ( 62 % ) and pretreatment prognostic index = 1 ( 56 % ) . During the follow-up period , 248 ( 95 % ) patients died , 246 from their disease . The median survival was 8 months . On multivariate analysis , age ( p = 0.001 ) , ECOG-PS ( p < 0.05 ) , mGPS ( p < 0.0001 ) , and tumor stage ( p < 0.0001 ) were independently associated with cancer-specific survival . Using 5-year cancer-specific mortality as an end point , the area under the receiver operator curve was 0.735 ( 95 % confidence interval [ CI ] , 0.566–0.903 ; p = 0.024 ) for the mGPS , 0.669 ( 95 % CI , 0.489–0.848 ; p = 0.106 ) for ECOG-PS , and 0.622 ( 95 % CI , 0.437–0.807 ; p = 0.240 ) for tumor , node , metastasis stage . Patients with an increased mGPS were more likely to have a poorer ECOG-PS ( p < 0.05 ) , an increased white cell count ( p < 0.05 ) , and received palliative treatment ( p < 0.05 ) . Conclusion : The pretreatment mGPS is a useful and important predictor of cancer-specific survival in patients with inoperable NSCLC . Basing clinical assessment on the mGPS has implication s for the routine monitoring and treatment of the patients This is one of a series of statements discussing the use of GI endoscopy in common clinical situations . The St and ards of Practice Committee of the American Society for Gastrointestinal Endoscopy ( ASGE ) prepared this text . In preparing this guideline , a search of the medical literature was performed by using PubMed . Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants . When few or no data exist from well- design ed prospect i ve trials , emphasis is placed on results from large series and reports from recognized experts . Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted . Further controlled clinical studies may be needed to clarify aspects of this guideline . This guideline may be revised as necessary to account for changes in technology , new data , or other aspects of clinical practice . The recommendations are based on review ed studies and are grade d on the quality of the supporting evidence ( Table 1 ) . The strength of individual recommendations is based on both the aggregate evidence quality and an assessment of the anticipated benefits and harms . Weaker recommendations are indicated by phrases such as ‘ ‘ we suggest , ’ ’ whereas stronger recommendations are typically stated as ‘ ‘ we recommend . ’ ’ This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients . This guideline is not a rule and should not be construed as establishing a legal st and ard of care or as encouraging , advocating , requiring , or discouraging any particular treatment . Clinical decisions in any particular case involve a complex analysis of the patient ’s condition and available courses of action . Therefore , clinical considerations may lead an endoscopist to take a course of action that varies from this guideline . Upper GI endoscopy has largely replaced upper GI barium x-ray series for the evaluation of upper GI tract disease or symptoms because it allows direct visualization , tissue acquisition , and therapeutic interventions . This guideline is an up date of a previous ASGE document and defines the role of upper GI endoscopy in the AIM Final 10-year analysis of the prospect i ve r and omised Chemo-N0 trial is presented . Based on the Chemo-N0 interim results and an European Organisation for Research and Treatment of Cancer ( EORTC ) pooled analysis ( n=8377 ) , American Society of Clinical Oncology ( ASCO ) and Arbeitsgemeinschaft Gynäkologische Onkologie ( AGO ) guidelines recommend invasion and metastasis markers urokinase-type plasminogen activator (uPA)/plasminogen activator inhibitor-1 ( PAI-1 ) for risk assessment and treatment decision in node-negative ( N0 ) breast cancer ( BC ) . METHODS The final Chemo-N0 trial analysis ( recruitment 1993 - 1998 ; n=647 ; 12 centres ) comprises 113 ( 5 - 167 ) months of median follow-up . Patients with low-uPA and PAI-1 tumour tissue levels ( n=283 ) were observed . External quality assurance guaranteed uPA/PAI-1 enzyme-linked immunosorbent assay ( ELISA ) st and ardisation . Of 364 high uPA and /or PAI-1 patients , 242 agreed to r and omisation for CMF chemotherapy ( n=117 ) versus observation ( n=125 ) . RESULTS Actuarial 10-year recurrence rate ( without any adjuvant systemic therapy ) for high-uPA/PAI-1 observation group patients ( r and omised and non-r and omised ) was 23.0 % , in contrast to only 12.9 % for low-uPA/PAI-1 patients ( plog-rank=0.011 ) . High-risk patients r and omised to cyclophosphamide-methotrexate-5-fluorouracil ( CMF ) therapy had a 26.0 % lower estimated probability of disease recurrence than those r and omised for observation ( intention-to-treat (ITT)- analysis : hazard ratio ( HR ) 0.74 ( 0.44 - 1.27 ) ; plog-rank=0.28 ) . Per- protocol analysis demonstrated significant treatment benefit : HR 0.48 ( 0.26 - 0.88 ) , p=0.019 , disease-free survival ( DFS ) Cox regression , adjusted for tumour stage and grade . CONCLUSIONS Chemo-N0 is the first prospect i ve biomarker-based therapy trial in early BC defining patients reaching good long-term DFS without adjuvant systemic therapy . Using a st and ardised uPA/PAI-1 ELISA , almost half of N0- patients could be spared chemotherapy , while high-risk patients benefit from adjuvant chemotherapy . These 10-year results vali date the long-term prognostic impact of uPA/PAI-1 and the benefit from  adjuvant chemotherapy  in the high-uPA/PAI-1 group at highest level of evidence . They thus support the guideline -based routine use of uPA/PAI-1 for risk-adapted individualised therapy decisions in N0 breast cancer PURPOSE The aim of this guideline is to present recommendations regarding moderately hypofractionated ( 240 - 340 cGy per fraction ) and ultrahypofractionated ( 500 cGy or more per fraction ) radiation therapy for localized prostate cancer . METHODS AND MATERIAL S The American Society for Radiation Oncology convened a task force to address 8 key questions on appropriate indications and dose-fractionation for moderately and ultrahypofractionated radiation therapy , as well as technical issues , including normal tissue dose constraints , treatment volumes , and use of image guided and intensity modulated radiation therapy . Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and Society-approved tools for grading evidence quality and recommendation strength . RESULTS Based on high- quality evidence , strong consensus was reached for offering moderate hypofractionation across risk groups to patients choosing external beam radiation therapy . The task force conditionally recommends ultrahypofractionated radiation may be offered for low- and intermediate-risk prostate cancer but strongly encourages treatment of intermediate-risk patients on a clinical trial or multi-institutional registry . For high-risk patients , the task force conditionally recommends against routine use of ultrahypofractionated external beam radiation therapy . With any hypofractionated approach , the task force strongly recommends image guided radiation therapy and avoidance of nonmodulated 3-dimensional conformal techniques . CONCLUSIONS Hypofractionated radiation therapy provides important potential advantages in cost and convenience for patients , and these recommendations are intended to provide guidance on moderate hypofractionation and ultrahypofractionation for localized prostate cancer . The limits in the current evidentiary base-especially for ultrahypofractionation-highlight the imperative to support large-scale r and omized clinical trials and underscore the importance of shared decision making between clinicians and patients BACKGROUND In 2001 , the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments ( CANMAT ) partnered to produce evidence -based clinical guidelines for the treatment of depressive disorders . A revision of these guidelines was undertaken by CANMAT in 2008 - 2009 to reflect advances in the field . There is renewed interest in refined approaches to brain stimulation , particularly for treatment resistant major depressive disorder ( MDD ) . METHODS The CANMAT guidelines are based on a question -answer format to enhance accessibility to clinicians . An evidence -based format was used with up date d systematic review s of the literature and recommendations were grade d according to Level of Evidence using pre-defined criteria . Lines of Treatment were identified based on criteria that included evidence and expert clinical support . This section on " Neurostimulation Therapies " is one of 5 guidelines articles . RESULTS Among the four forms of neurostimulation review ed in this section , electroconvulsive therapy ( ECT ) has the most extensive evidence , spanning seven decades . Repetitive transcranial magnetic ( rTMS ) and vagus nerve stimulation ( VNS ) have been approved to treat depressed adults in both Canada and the United States with a much smaller evidence base . There is also emerging evidence that  deep brain stimulation ( DBS )  is effective for otherwise treatment resistant depression , but this is an investigational approach in 2009 . LIMITATIONS Compared to other modalities for the treatment of MDD , the data based is limited by the relatively small numbers of r and omized controlled trials ( RCTs ) and small sample sizes . CONCLUSIONS There is most evidence to support ECT as a first-line treatment under specific circumstances and rTMS as a second-line treatment . Evidence to support VNS is less robust and DBS remains an investigational treatment The European Hernia Society ( EHS ) is proud to present the EHS Guidelines for the Treatment of  Inguinal Hernia in Adult Patients . The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare . They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS . They are evidence -based and , when necessary , a consensus was reached among all members . The Guidelines have been review ed by a Steering Committee . Before finalisation , feedback from different national hernia societies was obtained . The  Appraisal of Guidelines for REsearch and Evaluation ( AGREE ) instrument was used by the Cochrane Association to vali date the Guidelines . The Guidelines can be used to adjust local protocol s , for training purpose s and quality control . They will be revised in 2012 in order to keep them up date d. In between revisions , it is the intention of the Working Group to provide every year , during the EHS annual congress , a short up date of new high-level evidence ( r and omised controlled trials [ RCTs ] and meta-analyses ) . Developing guidelines leads to questions that remain to be answered by specific research . Therefore , we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment . In addition , a short summary , specifically for the general practitioner , is given . In order to increase the practical use of the Guidelines by consultants and residents , more details on the most important surgical techniques , local infiltration anaesthesia and a patient information sheet is provided . The most important challenge now will be the implementation of the Guidelines in daily surgical practice . This remains an important task for the EHS . The establishment of an EHS school for teaching inguinal hernia repair surgical techniques , including tips and tricks from experts to overcome the learning curve ( especially in endoscopic repair ) , will be the next step . Working together on this project was a great learning experience , and it was worthwhile and fun . Cultural differences between members were easily overcome by educating each other , respecting different views and always coming back to the principles of evidence -based medicine . The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project OBJECTIVE The aim of the present work was to make recommendations about the use of systemically administered drugs in combination or in sequence with radiation ( rt ) or surgery , or both , for cure or organ preservation , or both , in patients with locally advanced nonmetastatic ( stages iii-ivb ) squamous cell carcinoma of the head and neck ( lascchn ) . METHODS The Meta- analysis of Chemotherapy in Head and Neck Cancer ( mach-nc ) reports have , de facto , guided practice since 2000 , and so we search ed the literature for systematic review s published from January 2000 to February 2015 in reference to five research questions . A search was also conducted up to February 2015 for r and omized trials ( rcts ) not included in the meta-analyses . Recommendations were constructed using the Cancer Care Ontario Program in Evidence -Based Care practice guidelines development cycle . RESULTS In addition to up date d mach-nc reports , five additional meta-analyses and thirty rcts were identified . Five recommendations for lascchn treatment were generated based on those data . Concurrent chemoradiation ( ccrt ) is recommended to maximize the chance of cure in patients less than 71 years of age when rt is used as definitive treatment . The same recommendation also applies to patients with resected lascchn considered to be at high risk for locoregional recurrence . For lascchn patients who are c and i date s for organ preservation strategies and would otherwise require total laryngectomy , either ccrt or induction chemotherapy , followed by rt or surgery based on tumour response is recommended . The addition of cetuximab to intensified rt ( concomitant boost or hyperfractionated schedule ) is an alternative to ccrt . Routine use of induction chemotherapy to improve overall survival is not recommended . CONCLUSIONS We were able to use high-level evidence from patients receiving rt as definitive or postoperative treatment to generate recommendations for the use of systemic therapy in the treatment of lascchn . A limitation is a lack of stratification for human papillomavirus-related cancers of the oropharynx . One rct provided evidence for the use of cetuximab as an alternative to chemotherapy in the definitive rt setting . Concurrent chemoradiation provides one strategy for larynx preservation , but the best strategy is unclear . Use of induction chemotherapy does not improve overall survival , and its use should be limited to patients requiring immediate tumour downsizing before local therapy Abstract Objectives . This 2013 up date of the practice guidelines for the biological treatment of unipolar depressive disorders was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry ( WFSBP ) . The goal has been to systematic ally review all available evidence pertaining to the treatment of unipolar depressive disorders , and to produce a series of practice recommendations that are clinical ly and scientifically meaningful based on the available evidence . The guidelines are intended for use by all physicians seeing and treating patients with these conditions . Methods . The 2013 up date was conducted by a systematic up date literature search and appraisal . All recommendations were approved by the Guidelines Task Force . Results . This first part of the guidelines ( Part 1 ) covers disease definition , classification , epidemiology , and course of unipolar depressive disorders , as well as the management of the acute and continuation phase treatment . It is primarily concerned with the biological treatment ( including antidepressants , other psychopharmacological medications , electroconvulsive therapy , light therapy , adjunctive and novel therapeutic strategies ) of adults . Conclusions . To date , there is a variety of evidence -based antidepressant treatment options available . Nevertheless there is still a substantial proportion of patients not achieving full remission . In addition , somatic and psychiatric comorbidities and other special circumstances need to be more thoroughly investigated . Therefore , further high- quality informative r and omized controlled trials are urgently needed Background Evidence that chemotherapy improves survival and quality of life in patients with stage IIIB & IV non small cell lung cancer ( NSCLC ) is based on large r and omized controlled trials . The purpose of this study was to determine eligibility of patients with advanced NSCLC for major chemotherapy trials . Methods Physicians treating stage IIIB/IV NSCLC at Sydney Cancer Centre assessed patient eligibility for the E1594 , SWOG9509 and TAX326 trials for patients presenting from October 2001 to December 2002 . A review of the centre 's registry was used to obtain missing data . Results 199 patients with advanced NSCLC were registered during the 14-month period . Characteristics of 100 patients were defined prospect ively , 85 retrospectively : 77 % males , median age 68 ( range 32–88 ) , 64 % stage IV disease . Only 35 % met trial eligibility for E1594 and 28 % for SWOG9509 and TAX326 . Common reasons for in eligibility were : co-morbidities 75(40 % ) ; ECOG Performance Status ≥2 72(39 % ) ; symptomatic brain metastasis 15(8 % ) ; and previous cancers 21(11 % ) . Many patients were ineligible by more than one criterion . Conclusion The majority of patients with advanced NSCLC were ineligible for the large chemotherapy trials . The applicability of trial results to advanced lung cancer population s may be limited . Future trials should be conducted in a more representative population These guidelines have been developed at the request of the St and ards of Care Committee of the British Thoracic Society ( BTS ) and with the agreement of the Royal College of Radiologists and the British Society of Interventional Radiology , and approval of the Royal College of Pathologists in respect of the pathology recommendations and the Society of Cardiothoracic Surgeons of Great Britain and Irel and . Lung biopsy is a relatively frequently performed procedure with considerable benefit for patient management but it may , on rare occasions , result in the death of the patient . It is a multidisciplinary procedure involving respiratory physicians , surgeons , and radiologists with an interest in chest diseases . The aim of the group was to produce formal evidence based guidelines for subsequent use by those referring patients for the procedure and for those performing it . The areas covered by these guidelines are as follows : The following areas are not covered by these guidelines : # # # Validity and grading of recommendations The criteria for assessing the levels of evidence and grading of recommendations were based on those recommended in the Scottish Intercollegiate Guidelines Network in 19951 using the Agency of Health Care Policy and Research model used in some other BTS guidelines ( tables 1 and 2 ) . View this table : Table 1 Categories of evidence 185 View this table : Table 2 Grading of recommendations It should be noted that there are very few r and omised trials comparing the various aspects of lung biopsy and , for that reason , more detailed systems of categorisation such as that of the Scottish Intercollegiate Guidelines Network published in 2001 were not used.2 The papers selected by search ing PubMed and Medline were assessed by the members of the working group and decisions on levels of evidence for each paper were made by Objective : To provide information and recommendations to assist women with breast cancer and their physicians in making decisions regarding the use of locoregional post-mastectomy radiotherapy ( PMRT ) . Outcomes : Locoregional control , disease-free survival , overall survival and treatment-related toxicities . Evidence : This guideline is based on a review of all meta-analyses , consensus statements and other guidelines published between 1966 and November 2002 . Search es of MEDLINE and CANCERLIT for English- language r and omized controlled trials published between 1995 and November 2002 were also conducted to supplement the literature previously review ed by the American Society of Clinical Oncology ( ASCO ) Health Services Research Committee panel in its published guideline . A non systematic review of the literature was continued through June 2003 . Recommendations : Locoregional PMRT is recommended for women with an advanced primary tumour ( tumour size 5 cm or greater , or tumour invasion of the skin , pectoral muscle or chest wall ) . Locoregional PMRT is recommended for women with 4 or more positive axillary lymph nodes . The role of PMRT in women with 1 to 3 positive axillary lymph nodes is unclear . These women should be offered the opportunity to participate in clinical trials of PMRT . Locoregional PMRT is generally not recommended for women who have tumours that are less than 5 cm in diameter and who have negative axillary nodes . Other patient , tumour and treatment characteristics , including age , histologic grade , lymphovascular invasion , hormone receptor status , number of axillary nodes removed , axillary extracapsular extension and surgical margin status , may affect locoregional control , but their use in specifying additional indications for PMRT is currently unclear . PMRT should encompass the chest wall and the supraclavicular , infraclavicular and axillary apical lymph node areas . To reduce the risk of lymphedema , radiation of the entire axilla should not be used routinely after complete axillary dissection of level I and II lymph nodes . A definite recommendation regarding the inclusion of the internal mammary lymph nodes in PMRT can not be made because of limited and inconsistent data . The use of modern techniques in radiotherapy planning is recommended to minimize excessive normal tissue exposure , particularly to the cardiac and pulmonary structures . Common short-term side effects of PMRT , including fatigue and skin erythema , are generally tolerable and not dose-limiting . Severe long-term side effects , including lymphedema , cardiac and pulmonary toxicities , brachial plexopathy , rib fractures and secondary neoplasms , are relatively rare . The optimal sequencing of PMRT and systemic therapy is currently unclear . Regimens containing anthracyclines or taxanes should not be administered concurrently with radiotherapy because of the potential for increased toxicity . Validation : The authors ' original text was su bmi tted for review , revision and approval by the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer . Subsequently , feedback was provided by 11 oncologists from across Canada . The final document was approved by the steering committee . Sponsor : The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer was convened by Health Canada . Completion date : November 2003 CONTEXT AND OBJECTIVES The European Association of Urology Guideline Group for renal cell carcinoma ( RCC ) has prepared these guidelines to help clinicians assess the current evidence -based management of RCC and to incorporate the present recommendations into daily clinical practice . EVIDENCE ACQUISITION The recommendations provided in the current up date d guidelines are based on a thorough review of available RCC guidelines and review articles combined with a systematic literature search using Medline and the Cochrane Central Register of Controlled Trials . EVIDENCE SYNTHESIS A number of recent prospect i ve r and omised studies concerning RCC are now available with a high level of evidence , whereas earlier publications were based on retrospective analyses , including some larger multicentre validation studies , meta-analyses , and well- design ed controlled studies . CONCLUSIONS These guidelines contain information for the treatment of an individual patient according to a current st and ardised general approach . Up date d recommendations concerning diagnosis , treatment , and follow-up can improve the clinical h and ling of patients with RCC The publication of major studies dealing with the natural history of bradyarrhythmias and tachyarrhythmias and major advances in the technology of pacemakers and implantable cardioverter-defibrillators ( ICDs ) has m and ated this revision of the 1991 ACC/AHA Guidelines for Implantation of Pacemakers and Antiarrhythmia Devices . This executive summary appears in the April 7 , 1998 issue of Circulation . The full text of the guidelines , including the ACC/AHA Class I , II , and III recommendations , is published in the April 1998 issue of the Journal of the American College of Cardiology . Reprints of both the executive summary and the full text are available from both organizations . Following extensive review of the medical literature and related documents previously published by the American College of Cardiology , the American Heart Association , and the North American Society for Pacing and Electrophysiology , the writing committee developed recommendations that are evidence based whenever possible . Evidence supporting current recommendations is ranked as level A if the data were derived from multiple r and omized clinical trials involving a large number of individuals . Evidence was ranked as level B when data were derived from a limited number of trials involving comparatively small numbers of patients or from well- design ed data analysis of nonr and omized studies or observational data registries . Evidence was ranked as level C when consensus of expert opinion was the primary source of recommendation . The committee emphasizes that for certain conditions for which no other therapies are available , the indications for device therapies are based on years of clinical experience as well as expert consensus and are thus well supported , even though the evidence was ranked as level C. These guidelines include exp and ed sections on selection of pacemakers and ICDs , optimization of technology , cost , and follow-up of implanted devices . The follow-up sections are relatively brief because in many instances the type and frequency of follow-up examinations PURPOSE Overexpression of the excision repair cross-complementing 1 ( ERCC1 ) gene , which is crucial in the repair of cisplatin (CDDP)-DNA adducts , is reported to negatively influence the effectiveness of CDDP-based therapy for gastric and ovarian cancers . Recent evidence indicates that Gemcitabine ( Gem ) may modulate ERCC1 nucleotide excision repair activity , and down-regulation of DNA repair activity by ERCC1 antisense RNA reportedly inhibits synergism of CDDP/Gem . We investigated whether ERCC1 mRNA expression levels were associated with clinical outcomes after treatment with a combination Gem/CDDP regimen for patients with advanced stage non-small cell lung cancer ( NSCLC ) . EXPERIMENTAL DESIGN Response and survival were correlated with the level of ERCC1 expression in 56 patients with advanced ( stage IIIb or IV ) NSCLC treated as part of a multicenter r and omized trial with Gem 1250 mg/m(2 ) days 1 and 8 plus CDDP 100 mg/m(2 ) on day 1 every 3 weeks . mRNA was isolated from paraffin-embedded pretreatment primary tumor specimens , and relative expression levels of ERCC1/beta-actin were measured using a quantitative reverse transcription-PCR ( Taqman ) system . RESULTS ERCC1 expression was detectable in all tumors . There were no significant differences in ERCC1 levels by gender , age , performance status , weight loss , or tumor stage . The overall response rate was 44.7 % . There were no significant associations between ERCC1 expression and response . Median overall survival was significantly longer in patients with low ERCC1 expression tumors ( 61.6 weeks ; 95 % confidence interval , 42.4 - 80.7 weeks ) compared to patients with high expression tumors ( 20.4 weeks , 95 % confidence interval , 6.9 - 33.9 weeks ) . ERCC1 expression , Eastern Cooperative Oncology Group performance status , and presence of weight loss were significant prognostic factors for survival in a Cox proportional hazards multivariable analysis . CONCLUSIONS These data suggest that ERCC1 expression is a predictive factor for survival after CDDP/Gem therapy in advanced NSCLC . Although there was a trend toward decreased response with high ERCC1 mRNA levels , this difference failed to reach statistical significance . This result may reflect the impact of Gem and the requirement for ERCC1 expression for CDDP/Gem synergism or may be attributable to the relatively small patient sample size in this study . Prospect i ve studies of ERCC1 as a predictive marker for activity of CDDP-based regimens in NSCLC are warranted The st and ard of care for most patients with non-muscle-invasive bladder cancer ( NMIBC ) is immunotherapy with intravesical Bacillus Calmette-Guérin ( BCG ) , which activates the immune system to recognize and destroy malignant cells and has demonstrated durable clinical benefit . Urologic best- practice guidelines and consensus reports have been developed and strengthened based on data on the timing , dose , and duration of therapy from r and omized clinical trials , as well as by critical evaluation of criteria for progression . However , these reports have not penetrated the community , and many patients do not receive appropriate therapy . Additionally , several immune checkpoint inhibitors have recently been approved for treatment of metastatic disease . The approval of immune checkpoint blockade for patients with platinum-resistant or -ineligible metastatic bladder cancer has led to considerations of exp and ed use for both advanced and , potentially , localized disease . To address these issues and others surrounding the appropriate use of immunotherapy for the treatment of bladder cancer , the Society for Immunotherapy of Cancer ( SITC ) convened a Task Force of experts , including physicians , patient advocates , and nurses , to address issues related to patient selection , toxicity management , clinical endpoints , as well as the combination and sequencing of therapies . Following the st and ard approach established by the Society for other cancers , a systematic literature review and analysis of data , combined with consensus voting was used to generate guidelines . Here , we provide a consensus statement for the use of immunotherapy in patients with bladder cancer , with plans to up date these recommendations as the field progresses The st and ard of care for most patients with non-muscle-invasive bladder cancer ( NMIBC ) is immunotherapy with intravesical Bacillus Calmette-Guérin ( BCG ) , which activates the immune system to recognize and destroy malignant cells and has demonstrated durable clinical benefit . Urologic best- practice guidelines and consensus reports have been developed and strengthened based on data on the timing , dose , and duration of therapy from r and omized clinical trials , as well as by critical evaluation of criteria for progression . However , these reports have not penetrated the community , and many patients do not receive appropriate therapy . Additionally , several immune checkpoint inhibitors have recently been approved for treatment of metastatic disease . The approval of immune checkpoint blockade for patients with platinum-resistant or -ineligible metastatic bladder cancer has led to considerations of exp and ed use for both advanced and , potentially , localized disease . To address these issues and others surrounding the appropriate use of immunotherapy for the treatment of bladder cancer , the Society for Immunotherapy of Cancer ( SITC ) convened a Task Force of experts , including physicians , patient advocates , and nurses , to address issues related to patient selection , toxicity management , clinical endpoints , as well as the combination and sequencing of therapies . Following the st and ard approach established by the Society for other cancers , a systematic literature review and analysis of data , combined with consensus voting was used to generate guidelines . Here , we provide a consensus statement for the use of immunotherapy in patients with bladder cancer , with plans to up date these recommendations as the field progresses * The up date s are underlined for quick reference . INTRODUCTION A critical need exists for efficient , measurable systems of disease management that reconcile conflicts between socioeconomic responsibility and patient welfare . Clinical guidelines have become an important component of these systems because they address elements of care that are effective and that reduce the variability in our approach to patient management . The American Association of Clinical Endo-crinologists ( AACE ) 2001 Medical Guidelines for Clinical Practice for the Prevention and Management of Postmenopausal Osteoporosis address the prevention , diagnosis , and management of postmenopausal osteoporo-sis , a disorder that is recognized as a major public health problem because of its physical and socioeconomic consequences . They are intended to simplify medical decision making and to help physicians and their patients make good decisions about skeletal health and postmenopausal osteoporosis . The specific goals of these guidelines are to reduce the incidence of fractures related to osteoporosis and to achieve the highest quality of life for individual patients by using the most effective and efficient methods of diagnosis and management . In the preparation of this 2001 edition , reports in the peer- review ed literature dealing with prevention , diagnosis , and treatment of postmenopausal osteoporosis , which were published and indexed between 1996 ( the publication date of the previous edition of these guidelines ) and January 2001 , were identified by computer search , review ed , and grade d for clinical relevance and scientific merit . Although cost-effectiveness was carefully considered , variabilities in actual costs could not be accurately determined . Therefore , cost-effectiveness modeling was not undertaken . Whenever possible , recommendations were based on r and omized , prospect i ve , double-blind studies of well-defined patient population s. Studies that used the most relevant clinical endpoint , fracturing , were considered " level 1 " evidence . When level 1 evidence was not available , recommendations were based on cross-sectional studies , investigations that tested smaller or nonr and omized patient population s , or studies that tested secondary or surrogate clinical endpoints for fracture , such as bone mineral density ( BMD ) or bone turnover markers , in treated population s ( level 2 evidence ) . When stronger evidence was not available , review s , editorials , and expert opinions were used ( level 3 evidence ) . We recognize that the process of developing clinical guidelines necessarily results in a narrowing and codifica-tion of clinical choices , which can be inappropriate in some clinical situations . Because the application of objective information to the specific needs of patients is the ultimate responsibility of the practicing physician , clinical practice guidelines are not intended to be rigid or restrictive , nor ABSTRACT Immune checkpoint inhibitors ( ICIs ) are new therapeutic strategies for non-small cell lung cancer ( NSCLC ) . We aim ed to quantitatively evaluate the efficacy and safety of ICIs in NSCLC . Pubmed , Embase , Cochrane Library , and Web of Science were search ed for r and omized clinical trials comparing ICIs with control therapies in NSCLC . Data were pooled according to Preferred Reporting Items for Systematic Review s and Meta-analyses guidelines . A total of 12 trails comprising 6,919 NSCLC patients were included in this meta- analysis . ICIs therapies significantly improved progression-free survival ( PFS ) ( HR , 0.838 ; P < 0.001 ) , overall survival ( OS ) ( HR , 0.747 ; P < 0.001 ) and objective response rates ( ORR ) ( RR , 1.311 ; P < 0.001 ) in NSCLC . Prognostic benefit was observed irrespective of age , sex , treatment line , performance status and histology . Survival improvement of ICIs  was limited for NSCLC patients with non-smoker ( PFS , P = 0.468 ; OS , P = 0.317 ) or central nervous system ( CNS ) metastasis ( PFS , P = 0.209 ; OS , P = 0.090 ) , or positive EGFR mutation ( PFS , P = 0.083 ; OS , P = 0.522 ) or PD-L1 expression level less than 5 % ( PFS , P = 0.370 ; OS , P = 0.047 ) . The relative risks of all- grade and high- grade ( ≥3 ) anemia , neutropenia , leukopenia , thrombocytopenia , stomatitis , nausea , pyrexia , asthenia and neuropathy were all decreased in patients received ICIs compared with control therapies . This meta- analysis provides clinical evidence that ICIs improve PFS , OS , and ORR in NSCLC with fewer adverse effects . Our data establish ICIs as a prefer treatment option for NSCLC patients with smoker , no CNS metastasis , wild type EGFR , and high PD-L1 expression Background : Two prevalent unmet supportive care needs reported by the non – small cell lung cancer ( NSCLC ) population include the need to manage fatigue and attain adequate exercise to meet the physical dem and s of daily living . Yet , there are no guidelines for routine rehabilitative support to address fatigue and exercise for persons with NSCLC during the critical transition from hospital to home after thoracotomy . Objective : The objective of this study was to evaluate the feasibility , acceptability , safety , and changes in study end points of a home-based exercise intervention to enhance perceived self-efficacy for cancer-related fatigue ( CRF ) self-management for persons after thoracotomy for NSCLC transitioning from hospital to home . Interventions / Methods : Guided by the principles of the Transitional Care Model and the Theory of Symptom Self-management , a single-arm design composed of 7 participants with early-stage NSCLC performed light-intensity walking and balance exercises in a virtual reality environment with the Nintendo Wii Fit Plus . Exercise started the first week after hospitalization for thoracotomy and continued for 6 weeks . Results : The intervention positively impacted end points such as CRF severity ; perceived self-efficacy for fatigue self-management , walking , and balance ; CRF self-management behaviors ( walking and balance exercises ) ; and functional performance ( number of steps taken per day ) . Conclusions : A home-based , light-intensity exercise intervention for patients after thoracotomy for NSCLC is feasible , safe , well tolerated , and highly acceptable showing positive changes in CRF self-management . Implication s for Practice : Beginning evidence suggests that a light-intensity in-home walking and balance intervention after hospitalization for thoracotomy for NSCLC is a potentially effective rehabilitative CRF self-management intervention . Next steps include testing of this health-promoting self-management intervention in a larger-scale r and omized controlled trial Background Patients with advanced stage non-small cell lung cancer ( NSCLC ) or small cell lung cancer ( SCLC ) often experience multidimensional impairments , affecting quality of life during their course of disease . In lung cancer patients with operable disease , several studies have shown that exercise has a positive impact on quality of life and physical functioning . There is limited evidence regarding efficacy for advanced lung cancer patients undergoing palliative treatment . Therefore , the POSITIVE study aims to evaluate the benefit of a 24-week exercise intervention during palliative treatment in a r and omized controlled setting . Methods / design The POSITIVE study is a r and omized , controlled trial investigating the effects of a 24-week exercise intervention during palliative treatment on quality of life , physical performance and immune function in advanced , non-operable lung cancer patients . 250 patients will be recruited in the Clinic for Thoracic Diseases in Heidelberg , enrolment begun in November 2013 . Main inclusion criterion is histologically confirmed NSCLC ( stage IIIa , IIIb , IV ) or SCLC ( Limited Disease-SCLC , Extensive Disease-SCLC ) not amenable to surgery . Patients are r and omized into two groups . Both groups receive weekly care management phone calls ( CMPCs ) with the goal to assess symptoms and side effects . Additionally , one group receives a combined resistance and endurance training ( 3x/week ) . Primary endpoints are quality of life assessed by the Functional Assessment of Cancer Therapy for patients with lung cancer ( FACT-L , subcategory Physical Well-Being ) and General Fatigue measured by the Multidimensional Fatigue Inventory ( MFI-20 ) . Secondary endpoints are physical performance ( maximal voluntary isometric contraction , 6-min walk distance ) , psychosocial ( depression and anxiety ) and immunological parameters and overall survival . Discussion The aim of the POSITIVE trial is the evaluation of effects of a 24-week structured and guided exercise intervention during palliative treatment stages . Analysis of various outcomes ( such as quality of life , physical performance , self-efficacy , psychosocial and immunological parameters ) will contribute to a better underst and ing of the potential of exercise in advanced lung cancer patients . In contrast to other studies with advanced oncological patients the POSITIVE trial provides weekly phone calls to support patients both in the intervention and control group and to segregate the impact of physical activity on quality of life . Trial registration Clinical Trials.gov NCT02055508 ( Date : December 12 , 2013 This document revises and up date s the original “ Guidelines for Coronary Angiography  , ” published in 1987 . This executive summary and recommendations appears in the May 4 , 1999 , issue of Circulation . The guidelines in their entirety , including the American College of Cardiology/American Heart Association ( ACC/AHA ) class I , II , and III recommendations , are published in the May 1999 issue of the Journal of the American College of Cardiology . Reprints of both the full text and executive summary and recommendations are available from both organizations . The frequent and still growing use of coronary angiography , its relatively high costs , its inherent risks , and the ongoing evolution of its indications provide the reasons for this revision . The committee appointed to develop this document included private practitioners and academicians who were selected to represent both experts in coronary angiography and senior clinician consultants . Representatives from the family practice and internal medicine professions were also included on the committee . In addition to review ing the original document , the committee conducted a search of the literature for the 10 years preceding development of these guidelines . Evidence was compiled and ranked by the committee . Whereas r and omized trials are often available for reference in the development of treatment guidelines , r and omized trials regarding the use of diagnostic procedures such as coronary angiography are rarely available . This document uses the ACC/AHA classifications of class I , II , and III . These classes summarize the indications for coronary angiography as follows : Class I : Conditions for which there is evidence and /or general agreement that this procedure is useful and effective . Class II : Conditions for which there is conflicting evidence and /or a divergence of opinion about the usefulness/efficacy of performing the procedure . Class IIa : Weight of evidence /opinion is in favor of usefulness/ efficacy . Class IIb : Usefulness/efficacy is less well established by evidence /opinion . Class III : Conditions for which there BACKGROUND Physicians are often asked about complementary therapies by patients with cancer , and data show that the interest in and use of these therapies among patients with cancer is common . Therefore , it is important to assess the current evidence base on the benefits and risks of complementary therapies ( modalities not historically used in modern Western medicine ) . METHODS A systematic literature review was carried out and recommendations were made according to the American College of Chest Physicians Evidence -Based Clinical Practice Guidelines development methodology . RESULTS A large number of r and omized controlled trials , systematic review s , and meta-analyses , as well as a number of prospect i ve cohort studies , met the predetermined inclusion criteria . These trials addressed many different issues pertaining to patients with lung cancer , such as symptoms of anxiety , mood disturbance , pain , quality of life , and treatment-related side effects . The available data cover a variety of interventions , including acupuncture , nutrition , mind-body therapies , exercise , and massage . The body of evidence supports a series of recommendations . An evidence d-based approach to modern cancer care should integrate complementary therapies with st and ard cancer therapies such as surgery , radiation , chemotherapy , and best supportive care measures . CONCLUSIONS Several complementary therapy modalities can be helpful in improving the overall care of patients with lung cancer BACKGROUND Abnormal uterine bleeding is the direct cause of a significant health care burden for women , their families , and society as a whole . Up to 30 % of women will seek medical assistance for this problem during their reproductive years . This guideline replaces previous clinical guidelines on the topic and is aim ed to enable health care providers with the tools to provide the latest evidence -based care in the diagnosis and the medical and surgical management of this common problem . OBJECTIVE To provide current evidence -based guidelines for the diagnosis and management of  abnormal uterine bleeding ( AUB ) among women of reproductive age . OUTCOMES Outcomes evaluated include the impact of AUB on quality of life and the results of interventions including medical and surgical management of AUB . METHODS Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of location in Canada , type of practice , subspecialty expertise , and general gynaecology background . The committee review ed relevant evidence in the English medical literature including published guidelines . Recommendations were established as consensus statements . The final document was review ed and approved by the Executive and Council of the SOGC . RESULTS This document provides a summary of up-to- date evidence regarding diagnosis , investigations , and medical and surgical management of AUB . The result ing recommendations may be adapted by individual health care workers when serving women with this condition . CONCLUSIONS Abnormal uterine bleeding is a common and sometimes debilitating condition in women of reproductive age . St and ardization of related terminology , a systematic approach to diagnosis and investigation , and a step-wise approach to intervention is necessary . Treatment commencing with medical therapeutic modalities followed by the least invasive surgical modalities achieving results satisfactory to the patient is the ultimate goal of all therapeutic interventions . EVIDENCE Published literature was retrieved through search es of MEDLINE and the Cochrane Library in March 2011 using appropriate controlled vocabulary ( e.g. uterine hemorrhage , menorrhagia ) and key words ( e.g. menorrhagia , heavy menstrual bleeding , abnormal uterine bleeding ) . Results were restricted to systematic review s , r and omized control trials/controlled clinical trials , and observational studies written in English and published from January 1999 to March 2011 . Search es were up date d on a regular basis and incorporated in the guideline to February 2013 . Grey ( unpublished ) literature was identified through search ing the websites of health technology assessment and health technology-related agencies , clinical practice guideline collection s , clinical trial registries , and national and international medical specialty societies . VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care ( Table ) . BENEFITS , HARMS , AND COSTS Implementation of the guideline recommendations will improve the health and well-being of women with abnormal uterine bleeding , their families , and society . The economic cost of implementing these guidelines in the Canadian health care system was not considered Background A phase III multi-centre r and omised trial ( ROSEL ) has been initiated to establish the role of stereotactic radiotherapy in patients with operable stage IA lung cancer . Due to rapid changes in radiotherapy technology and evolving techniques for image-guided delivery , guidelines had to be developed in order to ensure uniformity in implementation of stereotactic radiotherapy in this multi-centre study . Methods / Design A Quality Assurance Working Party was formed by radiation oncologists and clinical physicists from both academic as well as non-academic hospitals that had already implemented stereotactic radiotherapy for lung cancer . A literature survey was conducted and consensus meetings were held in which both the knowledge from the literature and clinical experience were pooled . In addition , a planning study was performed in 26 stage I patients , of which 22 were stage 1A , in order to develop and evaluate the planning guidelines . Plans were optimised according to parameters adopted from RTOG trials using both an algorithm with a simple homogeneity correction ( Type A ) and a more advanced algorithm ( Type B ) . Dose conformity requirements were then formulated based on these results . Conclusion Based on current literature and expert experience , guidelines were formulated for this phase III study of stereotactic radiotherapy versus surgery .  These guidelines can serve to facilitate the design of future multi-centre clinical trials of stereotactic radiotherapy in other patient groups and aid a more uniform implementation of this technique outside clinical trials PURPOSE To provide current recommendations about the prophylaxis and treatment of venous thromboembolism ( VTE ) in patients with cancer . METHODS PubMed and the Cochrane Library were search ed for r and omized controlled trials , systematic review s , meta-analyses , and clinical practice guidelines from November 2012 through July 2014 . An up date committee review ed the identified abstract s. RESULTS Of the 53 publications identified and review ed , none prompted a change in the 2013 recommendations . RECOMMENDATIONS Most hospitalized patients with active cancer require thromboprophylaxis throughout hospitalization . Routine thromboprophylaxis is not recommended for patients with cancer in the outpatient setting . It may be considered for selected high-risk patients . Patients with multiple myeloma receiving antiangiogenesis agents with chemotherapy and /or dexamethasone should receive prophylaxis with either low-molecular weight heparin ( LMWH ) or low-dose aspirin .  Patients undergoing major surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days . Extending prophylaxis up to 4 weeks should be considered in those undergoing major abdominal or pelvic surgery with high-risk features . LMWH is recommended for the initial 5 to 10 days of treatment for deep vein thrombosis and pulmonary embolism as well as for long-term secondary prophylaxis ( at least 6 months ) . Use of novel oral anticoagulants is not currently recommended for patients with malignancy and VTE because of limited data in patients with cancer . Anticoagulation should not be used to extend survival of patients with cancer in the absence of other indications . Patients with cancer should be periodically assessed for VTE risk . Oncology professionals should educate patients about the signs and symptoms of VTE PURPOSE To develop a guideline to improve the accuracy of immunohistochemical ( IHC ) estrogen receptor ( ER ) and progesterone receptor ( PgR ) testing in breast cancer and the utility of these receptors as predictive markers . METHODS The American Society of Clinical Oncology and the College of American Pathologists convened an international Expert Panel that conducted a systematic review and evaluation of the literature in partnership with Cancer Care Ontario and developed recommendations for optimal IHC ER/PgR testing performance . RESULTS Up to 20 % of current IHC determinations of ER and PgR testing worldwide may be inaccurate ( false negative or false positive ) . Most of the issues with testing have occurred because of variation in preanalytic variables , thresholds for positivity , and interpretation criteria . RECOMMENDATIONS The Panel recommends that ER and PgR status be determined on all invasive breast cancers and breast cancer recurrences . A testing algorithm that relies on accurate , reproducible assay performance is proposed . Elements to reliably reduce assay variation are specified . It is recommended that ER and PgR assays be considered positive if there are at least 1 % positive tumor nuclei in the sample on testing in the presence of expected reactivity of internal ( normal epithelial elements ) and external controls . The absence of benefit from endocrine therapy for women with ER-negative invasive breast cancers has been confirmed in large overviews of r and omized clinical trials OBJECTIVE The purpose of this article is to compare the recently published revised Response Evaluation Criteria in Solid Tumors ( RECIST ) guidelines ( version 1.1 ) to the original guidelines ( RECIST 1.0 ) for advanced non-small cell lung cancer ( NSCLC ) after erlotinib therapy and to evaluate the impact of the new CT tumor measurement guideline on response assessment . MATERIAL S AND METHODS Forty-three chemotherapy-naive patients with advanced NSCLC treated with erlotinib in a single-arm phase 2 multicenter open-label clinical trial were retrospectively studied . CT tumor measurement records using RECIST 1.0 that were generated as part of the prospect i ve clinical trial were review ed . A second set of CT tumor measurements  was generated from the records to meet RECIST 1.1 guidelines . The number of target lesions , best response , and time to progression were compared between RECIST 1.1 and RECIST 1.0 . RESULTS The number of target lesions according to RECIST 1.1 decreased in 22 patients ( 51 % ) and did not change in 21 patients ( 49 % ) compared with the number according to RECIST 1.0 ( p < 0.0001 , paired Student 's t test ) . Almost perfect agreement was observed between best responses using RECIST 1.1 and RECIST 1.0 ( weighted kappa = 0.905 ) . Two patients with stable disease according to RECIST 1.0 had progressive disease according to RECIST 1.1 criteria because of new lesions found on PET/CT . There was no significant difference in time to progression between RECIST 1.1 and RECIST 1.0 ( p = 1.000 , sign test ) . CONCLUSION RECIST 1.1 provided almost perfect agreement in response assessment after erlotinib therapy compared with RECIST 1.0 . Assessment with PET/CT was a major factor that influenced the difference in best response assessment between RECIST 1.1 and RECIST 1.0 Recent advances in the treatment of non-small cell lung cancer ( NSCLC ) have led to improvements in patient survival and quality of life . It is unclear whether molecular abnormalities associated with NSCLC cell survival , growth and proliferation are useful in predicting treatment benefit . We conducted a systematic review to establish which biomarkers contribute meaningfully to the management of NSCLC . A team of research ers search ed PubMed and conference proceedings ( ASCO , ESMO , IASLC , USCAP ) using MESH terms for NSCLC and r and omized trials ( RCT ) , plus keywords for variables of interest . Evidence from multiple RCTs confirmed that histologic subtype is prognostic for survival and predictive of treatment efficacy and /or toxicity in NSCLC . Likewise , activating mutations of the epidermal growth factor receptor ( EGFR ) are associated with benefit from EGFR tyrosine kinase inhibitors in patients with advanced non-squamous NSCLC and should be assessed routinely . No biomarkers to date reliably predict response to anti-Vascular Endothelial Growth Factor ( VEGF ) therapies . There are inconsistent data on the role of ERCC1 , BRCA , Beta tubulin III , RRM1 , K-RAS , or TP-53 in treatment decisions . These tests should not be routinely used in selecting treatment at this time , whereas EML4/ALK translocations predict responses to specific targeted agents , the optimal assessment of this molecular abnormality has yet to be established . Personalized care of patients with NSCLC based on biomarkers is increasingly important to both clinical practice and research PURPOSE To test the concept of taxane sequencing in combined-modality therapy , this phase II trial ( S9504 ) evaluated consolidation docetaxel after concurrent chemoradiotherapy in patients with pathologically documented stage IIIB non-small-cell lung cancer ( NSCLC ) . Results were compared with those of the predecessor study ( S9019 ) with identical eligibility , staging criteria , and treatment , excepting docetaxel consolidation . PATIENTS AND METHODS Treatment consisted of cisplatin 50 mg/m2 on days 1 , 8 , 29 , and 36 , etoposide 50 mg/m2 on days 1 through 5 and 29 through 33 , and concurrent thoracic radiotherapy ( total dose of 61 Gy ) . Consolidation docetaxel started 4 to 6 weeks after chemoradiotherapy at an initial dose of 75 mg/m2 . RESULTS Stage subsets ( tumor-node-metastasis system ) in 83 eligible patients were as follows : T4N0/1 , 31 patients ( 37 % ) ; T4N2 , 22 patients ( 27 % ) , and T1 - 3N3 , 30 patients ( 36 % ) . Concurrent chemoradiotherapy was generally well tolerated , but two patients died from probable radiation-associated pneumonitis . Neutropenia during consolidation docetaxel was common ( 57 % with grade 4 ) and most frequent during escalation to 100 mg/m2 . Median progression-free survival was 16 months , median survival was 26 months , and 1- , 2- , and 3-year survival rates were 76 % , 54 % , and 37 % , respectively . Brain metastasis was the most common site of failure . In S9019 , median survival was 15 months and 1- , 2- , and 3-year survival rates were 58 % , 34 % , and 17 % , respectively . CONCLUSION Consolidation docetaxel after concurrent chemoradiotherapy in stage IIIB NSCLC is feasible and generally tolerable , and results compare favorably with the predecessor trial S9019 . Nevertheless , this study remains hypothesis-generating and does not provide definitive evidence of the benefit of this approach . Phase III trials evaluating the S9504 regimen have been initiated to vali date these results Practice guidelines are valid if “ they lead to the health gains and costs predicted for them.”1 When implemented , valid guidelines lead to changes in clinical practice and improvements in outcomes for patients .2 - 5 Invalid guidelines , however , may lead to the use of ineffective interventions that waste re sources , or even to harm . Guidelines must offer recommendations for both effective and efficient care , and these have not previously been available in the United Kingdom . We have reported the development and content of guidelines for primary care in the United Kingdom based explicitly on evidence of effectiveness.6 - 9 Here , we present the methods used to develop evidence based guidelines on the use in primary care of four important groups of drugs — angiotensin converting enzyme inhibitors in patients with heart failure , choice of antidepressants , non-steroidal anti-inflammatory drugs in patients with osteoarthritis , and aspirin as an antithrombotic agent.10 - 13 Abridged versions of the guidelines on angiotensin converting enzyme inhibitors , aspirin , and non-steroidal anti-inflammatory drugs will be published in subsequent articles.14 - 16 # # # # Summary points Guideline development groups defined important clinical questions , produced search criteria , and drew up protocol s for systematic review and , where appropriate , meta- analysis Medline and Embase were search ed for systematic review s and meta-analyses , r and omised trials , quality of life studies , and economic studies Meta- analysis was used extensively by the group to answer specific clinical questions Statements on evidence were categorised in relation to study design , reflecting their susceptibility to bias Strength of recommendations was grade d according to the category of evidence and its applicability , economic issues , values of the guideline group and society , and the groups ' awareness of practical issues Recommendations cease to apply in December 1999 , by which time relevant results that may affect recommendations may be known Guideline development groups comprised three broad classes of members — relevant healthcare professionals ( up to five general practitioners ( all with PURPOSE Validation of a prospect i ve , risk-adapted strategy for early-stage non-small-cell lung cancer ( NSCLC ) patients treated with stereotactic body radiotherapy ( SBRT ) .  METHODS AND MATERIAL S Patients with a T1 - 3N0M0 ( American Joint Committee on Cancer 6th edition ) NSCLC were accrued . Using the Radiation Therapy Oncology Group definition , patients were treated to a total dose of 60,Gy in three fractions for peripherally located lesions and four fractions for central ly located lesions . The primary endpoint was toxicity , grade d according to the Radiation Therapy Oncology Group acute and late morbidity scoring system , and the National Cancer Institute Common Terminology Criteria for Adverse Events Version 3.0 . Secondary endpoints were local control and survival . RESULTS A total of 40 patients were included , 17 with a central ly located lesion . The lung toxicity-free survival estimate at 2 years was 74 % and was related to the location ( central vs. peripheral ) and the size of the target volume . No dose volumetric parameters could predict the occurrence of lung toxicity . One patient died because of treatment-related toxicity . The 1-year and 2-year local progression-free survival estimates were 97 % and 84 % , respectively , and were related to stage ( T1 vs. T2 ) related ( p = 0.006 ) . Local failure was not more frequent for patients treated in four fractions . The 1-year local progression-free survival estimate dropped below 80 % for lesions with a diameter of more than 4 cm . CONCLUSION The proposed risk-adapted strategy for both central ly and peripherally located lesions showed an acceptable toxicity profile while maintaining excellent local control rates . The correlation between local control and tumor diameter calls for the inclusion of tumor stage as a variable in future study design PURPOSE To make recommendations regarding combined radiotherapy ( RT ) and chemotherapy ( RTCT ) , compared with RT alone , when a nonsurgical approach is used for patients with localized esophageal carcinoma . MATERIAL S AND METHODS The Medline , Cancerlit , Cochrane Library data bases , and abstract s published in the American Society of Clinical Oncology and the American Society for Therapeutic Radiology and Oncology proceedings were search ed for evidence . Evidence was evaluated by two members of the Gastrointestinal Cancer Disease Site Group and method ologists . RESULTS Pooling seven r and omized trials detected a statistically significant survival benefit at 1 year for concomitant RTCT compared with RT alone ( 1-year mortality odds ratio 0.61 ; 95 % confidence interval 0.44 - 0.84 ; p < 0.00001 ) . Local control also significantly improved with concomitant RTCT compared with RT alone for the available data ( odds ratio 0.52 ; 95 % confidence interval 0.31 - 0.89 ; p = 0.004 ) , but a significant increase in adverse effects , including life-threatening toxicities , was shown . CONCLUSIONS Concomitant RT and cisplatin-based CT is recommended over RT alone . Patients should be aware of the increased acute toxicity associated with this approach , and this recommendation should only be made after consideration of the potential risks and benefits and the patient 's general condition . Sequential RTCT is not recommended as st and ard practice Guidelines for the diagnosis and treatment of Barrett ’s esophagus were published by the American College of Gastroenterology in 1998 ( 1 ) . These and other guidelines undergo periodic review . Significant advances have been made in the area of Barrett ’s esophagus over the past several years , leading us to review and revise our previous guidelines statements . These advances have included more information on the natural history of high- grade dysplasia and the chronic use of proton pump inhibitors . These and the original guidelines are intended to apply to all physicians who address Barrett ’s and are intended to indicate the preferable , but not only acceptable , approach . Physicians must always choose the course best suited to the individual patient and the variables that exist at the moment of the decision . These guidelines are intended to apply to adult patients with the diagnosis of Barrett ’s esophagus defined in the guidelines . Both these and the original guidelines were developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees . The world literature was review ed extensively for the original guidelines and was once again review ed using the National Library of Medicine data base . All appropriate studies were review ed , and any additional studies found in the reference list of these papers were obtained and review ed . Evidence was evaluated along a hierarchy , with r and omized controlled trials given the greatest weight . Abstract s presented at national and international meetings were only used when unique data from ongoing trials were presented . When scientific data were lacking , recommendations were based on expert consensus . During preparation , the guidelines were review ed by the American Gastroenterological Association and the American Society for GI Endoscopy . Recommendations and comments obtained from these review s were incorporated into the final document whenever possible GUIDELINE QUESTIONS 1 ) Does erythropoietin ( EPO ) reduce the need for transfusion of red blood cells in patients receiving chemotherapy for a nonhematologic cancer ? 2 ) Does the administration of EPO improve the quality of life of these cancer patients ? OBJECTIVE To make recommendations regarding the use of EPO to reduce the need for transfusion of red blood cells in patients receiving chemotherapy for a nonhematologic cancer . OUTCOMES First transfusion requirement from the start of chemotherapy is the main outcome of interest . Quality of life and costs are also considered . PERSPECTIVE ( VALUES ) Evidence was selected and review ed by 5 members of the Ontario Cancer Treatment Practice Guidelines Initiative ( OCTPGI ) and the Systemic Treatment Program Committee ( STPC ) . Drafts of this document have been circulated to and review ed by members of the STPC . The STPC comprises medical oncologists , pharmacists , supportive care personnel and administrators . No community representative participated in the development of this practice guideline . QUALITY OF EVIDENCE Eleven r and omized controlled trials ( RCTs ) , most placebo-controlled , were available for review . A meta- analysis was performed with 8 trials that shared a clinical ly relevant outcome measure . Only 1 trial assessed quality of life . BENEFITS The meta- analysis showed a relative risk for transfusion among EPO patients of 0.64 ( 95 % confidence interval 0.53 - 0.78 ) , which translates into a 36 % relative reduction in the proportion of patients requiring transfusion ( p = 0.00001 ) . Reduction in transfusion requirements was similar across strata defined by method ological quality , EPO dose , hematologic status , tumour type at trial entry and chemotherapy regimen . In the 1 trial that assessed quality of life , EPO was associated with improved quality of life . HARMS Hypertension has been noted rarely in  EPO-treated cancer patients . The RCTs did not report adverse effects in EPO-treated patients compared with control patients during the follow-up period . Long-term adverse effects are unknown . EPO is more costly than transfusion , but formal cost-effectiveness studies are unavailable . PRACTICE GUIDELINE For patients receiving chemotherapy for nonhematologic cancer in whom symptoms of anemia are expected and in whom transfusion of red blood cells is not considered an acceptable treatment option , EPO can be recommended as a safe , effective treatment alternative . The evidence in support of using EPO is stronger for patients receiving platinum-based chemotherapy regimens that for those receiving non-platinum-based regimens . CLINICAL PRACTICE GUIDELINE DATE : Apr. 4 , 1997 PURPOSE Concurrent chemoradiotherapy is st and ard treatment for patients with inoperable stage III non-small-cell lung cancer ( NSCLC ) . A phase II study by the Southwest Oncology Group using consolidation docetaxel after cisplatin ( P ) , etoposide ( E ) , and radiation ( XRT ) result ed in a median survival time ( MST ) of 26 months . This r and omized phase III trial evaluated whether consolidation docetaxel was responsible for this improved survival . PATIENTS AND METHODS Eligible patients had stage IIIA or IIIB NSCLC , baseline performance status of 0 to 1 , forced expiratory volume in 1 second > or= 1 L , and less than 5 % weight loss . Patients received P 50 mg/m(2 ) intravenously ( IV ) on days 1 , 8 , 29 , and 36 and E 50 mg/m(2 ) IV on days 1 - 5 and 29 - 33 concurrently with chest XRT to 59.40 Gy . Patients who did not experience progression were r and omly assigned to docetaxel 75 mg/m(2 ) IV every 21 days for three cycles versus observation . The primary end point was to compare overall survival ( Kaplan-Meier analysis ) . RESULTS On the basis of evidence of futility , a data and safety monitoring board recommended early termination after an analysis of the initial 203 patients . Patient characteristics ( n = 203 ) were as follows : 34 % female ; median age , 63 years ; 39.4 % stage IIIA ; and 60.6 % stage IIIB . One hundred forty-seven ( 72.4 % ) of 203 patients were r and omly assigned to docetaxel ( n = 73 ) or observation ( n = 74 ) . Grade 3 to 5 toxicities during docetaxel included febrile neutropenia ( 10.9 % ) and pneumonitis ( 9.6 % ) ; 28.8 % of patients were hospitalized during docetaxel ( v 8.1 % in observation arm ) , and 5.5 % died as a result of docetaxel . The MST for all patients ( n = 203 ) was 21.7 months ; MST was 21.2 months for docetaxel arm compared with 23.2 months for observation arm ( P = .883 ) . CONCLUSION Consolidation docetaxel after PE/XRT results in increased toxicities but does not further improve survival compared with PE/XRT alone in patients with stage III inoperable NSCLC These guidelines provide a data -supported approach to the diagnosis and management of patients with autoimmune hepatitis . They are based on the following : ( 1 ) a formal review and analysis of the published world literature on autoimmune hepatitis ( 914 articles ) ( Medline Search from 1966 - 2002 ; the search term was autoimmune hepatitis ) ; ( 2 ) recommendations developed and published by the International Autoimmune Hepatitis Group ; ( 3 ) concepts developed at the AASLD Single Topic Conference on autoimmune hepatitis in September 1999 ; and ( 4 ) 40 years of combined experience by both authors in the clinical and laboratory investigation and care for patients with this disease . The guidelines , intended for use by physicians , are meant to be flexible , in contrast to “ st and ards of care , ” which are inflexible policies to be followed in almost every case . They have been developed in a manner consistent with the American Association for the Study of Liver Diseases ’ Policy Statement on Development and Use of Practice Guidelines . Specific recommendations are based on relevant published information . In an attempt to st and ardize recommendations , the Practice Guidelines Committee of the American Association for the Study of Liver Diseases modified the categories of the Infectious Diseases Society of America ’s Quality St and ards . These categories are reported with each recommendation , using the Roman numerals I through IV to determine the quality of evidence upon which the recommendations are based . The categories are as follows : I , evidence from multiple well- design ed r and omized controlled trials , each involving a number of participants to be of sufficient statistical power ; II , evidence from at least one large , well- design ed clinical trial with or without r and omization , from cohort or case-control analytic studies , or from well- design ed meta- analysis ; III , evidence based on clinical experience , descriptive studies , or reports of expert committees ; and IV , not rated PURPOSE A major problem with the staging system for non-small cell lung cancer ( NSCLC ) is clinical underestimation of the extent of disease . Many patients with clinical stage 1 disease do not retain that design ation following surgical resection . Herein , we present data from Cancer and Leukemia Group B ( CALGB ) protocol 9761 evaluating the correspondence between clinical and pathologic analysis in early stage NSCLC . METHODS Five hundred and two patients with suspected or biopsy-proven NSCLC classified as clinical stage 1 ( T1 - 2 , N0 ) by computed tomography ( CT ) scan or cervical mediastinoscopy were prospect ively enrolled in CALGB 9761 . The purpose of CALGB 9761 was to prospect ively evaluate molecular markers of micrometastatic disease in stage 1 NSCLC . Enrollment occurred at 11 selected institutions within the CALGB . Patients with clinical ly suspected resectable early stage lung cancer were eligible for enrollment if they had no evidence of mediastinal or hilar adenopathy on CT scan or if they had CT evidence of potential N2 or N3 disease ( lymph node > or = 1.0 cm ) but with negative mediastinoscopy . No prior chemotherapy  or  radiotherapy  was permitted . RESULTS Of the 502 patients felt to have clinical stage 1 NSCLC enrolled in CALGB 9761 , 489 underwent resection with complete surgical staging and routine histopathologic analysis . From these 489 patients , only 422 ( 86.3 % ) turned out to have pathologically documented NSCLC . Of these 422 patients , 302 ( 71.6 % ) had pathologic stage 1 disease ( 173 stage 1A and 129 stage 1B ) . Despite clinical assessment of stage 1 disease , 59 ( 14 % ) patients had pathologic stage 2 disease , 57 ( 13.5 % ) had stage 3 disease , and four ( 0.9 % ) patients had stage 4 disease . Of the patients undergoing resection for clinical stage 1 NSCLC , 65 patients did not have NSCLC ( 44 had benign disease and 21 had malignancies other than NSCLC ) and two additional patients had dual synchronous primary NSCLC tumors and were not eligible for the study . Overall , only 61.7 % ( 302 of 489 ) of patients with suspected stage 1 NSCLC disease retained that stage and diagnosis after complete surgical staging , while 38.3 % had an inaccurate pre-operative clinical stage or diagnosis . CONCLUSIONS The results from this prospect i ve trial demonstrate the poor predictive value of current clinical staging techniques in early stage NSCLC . These findings will serve as a benchmark for comparison of future clinical imaging modalities and other tests evaluating early stage NSCLC BACKGROUND In 2001 , the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments ( CANMAT ) partnered to produce evidence -based clinical guidelines for the treatment of depressive disorders .  A revision of these guidelines was undertaken by CANMAT in 2008 - 2009 to reflect advances in the field . This article , one of five in the series , review s new studies of psychotherapy in the acute and maintenance phase of MDD , including computer-based and telephone-delivered psychotherapy . METHODS The CANMAT guidelines are based on a question -answer format to enhance accessibility to clinicians . Evidence -based responses are based on up date d systematic review s of the literature and recommendations are grade d according to the Level of Evidence , using pre-defined criteria . Lines of Treatment are identified based on criteria that included evidence and expert clinical support . RESULTS Cognitive-Behavioural Therapy ( CBT ) and Interpersonal Therapy ( IPT ) continue to have the most evidence for efficacy , both in acute and maintenance phases of MDD , and have been studied in combination with antidepressants . CBT is well studied in conjunction with computer-delivered methods and bibliotherapy . Behavioural Activation and Cognitive-Behavioural Analysis System of Psychotherapy have significant evidence , but need replication . Newer psychotherapies including Acceptance and Commitment Therapy , Motivational Interviewing , and Mindfulness-Based Cognitive Therapy do not yet have significant evidence as acute treatments ; nor does psychodynamic therapy . LIMITATIONS Although many forms of psychotherapy have been studied , relatively few types have been evaluated for MDD in r and omized controlled trials . Evidence about the combination of different types of psychotherapy and antidepressant medication is also limited despite widespread use of these therapies concomitantly . CONCLUSIONS CBT and IPT are the only first-line treatment recommendations for acute MDD and remain highly recommended for maintenance . Both computer-based and telephone-delivered psychotherapy -- primarily studied with CBT and IPT -- are useful second-line recommendations . Where feasible , combined antidepressant and CBT or IPT are recommended as first-line treatments for acute MDD Malignant pleural mesothelioma ( MPM ) is a rare tumour but with increasing incidence and a poor prognosis . In 2008 , the European Respiratory Society/European Society of Thoracic Surgeons Task Force brought together experts to propose practical and up-to- date d guidelines on the management of MPM . To obtain an earlier and reliable diagnosis of MPM , the experts recommend performing thoracoscopy , except in cases of pre-operative contraindication or pleural symphysis . The st and ard staining procedures are insufficient in ∼10 % of cases . Therefore , we propose using specific immunohistochemistry markers on pleural biopsies . In the absence of a uniform , robust and vali date d staging system , we advice use of the most recent TNM based classification , and propose a three step pre-treatment assessment . Patient 's performance status and histological subtype are currently the only prognostic factors of clinical importance in the management of MPM . Other potential parameters should be recorded at baseline and reported in clinical trials . MPM exhibits a high resistance to chemotherapy and only a few patients are c and i date s for radical surgery . New therapies and strategies have been review ed . Because of limited data on the best combination treatment , we emphasise that patients who are considered c and i date s for a multimodal approach should be included in a prospect i ve trial at a specialised centre The guidelines for the diagnosis , surveillance and therapy of Barrett ’s esophagus were originally published by the American College of Gastroenterology in 1998 and up date d in 2002 . These and other guidelines undergo periodic review . Significant advances have occurred in the area of Barrett ’s esophagus over the past four years leading to another revision of the prior guidelines . These advances include the potential use of esophageal capsule endoscopy for the diagnosis and screening of Barrett ’s esophagus , data regarding the outcome of low- grade dysplasia , the treatment of high- grade dysplasia using photodynamic therapy , and the development of new ablation techniques such as radiofrequency ablation . These guidelines are intended to be applied by physicians who see Barrett ’s esophagus patients and are intended to indicate a preferred , but certainly not the only , acceptable approach . Physicians need to choose the course best suited to the individual patient and to the variables that exist at the time of decision making . The guidelines are for adult patients with the diagnosis of Barrett ’s esophagus , as defined herein . Both these and the original guidelines were developed under auspices of the American College of Gastroenterology and the Practice Parameters Committee and approved by the Board of Trustees . The world literature was review ed extensively for the original guidelines and once again review ed using the National Library of Medicine data base . Search terms used included Barrett ’s esophagus , esophageal neoplasm , esophagus , intestinal metaplasia , esophageal diseases , and adenocarcinoma , all appropriate studies and any additional ones found in reference to these papers were obtained and review ed . Evidence was available from a hierarchy of trials and r and omized controlled trials were given the greatest weight . Abstract s presented at national and international meetings were only used when unique data from ongoing trials were presented . When scientific data were lacking , recommendations are based on expert opinion . The recommendations made are based on the level of evidence found . Grade A recommendations imply that there is consistent level 1 evidence ( r and omized controlled trials ) , Grade B indicates that the evidence would be level 2 or 3 which are cohort studies or case control studies . Grade C recommendations are based on level 4 studies meaning case series or poor quality cohort studies , and Grade D recommendations are based on level 5 evidence meaning expert opinion During the past three decades , catheter and surgical ablation of  atrial fibrillation ( AF ) have evolved from investigational procedures to their current role as effective treatment options for patients with AF .  Surgical ablation of AF , using either st and ard , minimally invasive , or hybrid techniques , is available in most major hospitals throughout the world . Catheter ablation of AF is even more widely available , and is now the most commonly performed catheter ablation procedure . In 2007 , an initial Consensus Statement on Catheter and Surgical AF Ablation was developed as a joint effort of the Heart Rhythm Society ( HRS ) , the European Heart Rhythm Association ( EHRA ) , and the European Cardiac Arrhythmia Society (ECAS).1 The 2007 document was also developed in collaboration with the Society of Thoracic Surgeons ( STS ) and the American College of Cardiology ( ACC ) . This Consensus Statement on Catheter and Surgical AF Ablation was rewritten in 2012 to reflect the many advances in AF ablation that had occurred in the interim.2 The rate of advancement in the tools , techniques , and outcomes of AF ablation continue to increase as enormous research efforts are focused on the mechanisms , outcomes , and treatment of AF . For this reason , the HRS initiated an effort to rewrite and up date this Consensus Statement . Reflecting both the worldwide importance of AF , as well as the worldwide performance of AF ablation , this document is the result of a joint partnership between the HRS , EHRA , ECAS , the Asia Pacific Heart Rhythm Society ( APHRS ) , and the Latin American Society of Cardiac Stimulation and Electrophysiology ( Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia [ SOLAECE ] ) . The purpose of this 2017 Consensus Statement is to provide a state-of-the-art review of the field of catheter and surgical ablation of AF and to report the findings of a writing group , convened by these five international societies . The writing group is charged with defining the indications , techniques , and outcomes of AF ablation procedures . Included within this document are recommendations pertinent to the design of clinical trials in the field of AF ablation and the reporting of outcomes , including definitions relevant to this topic . The writing group is composed of 60 experts representing 11 organizations : HRS , EHRA , ECAS , APHRS , SOLAECE , STS , ACC , American Heart Association ( AHA ) , Canadian Heart Rhythm Society ( CHRS ) , Japanese Heart Rhythm Society ( JHRS ) , and Brazilian Society of Cardiac Arrhythmias ( Sociedade Brasileira de Arritmias Cardiacas [ SOBRAC ] ) . All the members of the writing group , as well as peer review ers of the document , have provided disclosure statements for all relationships that might be perceived as real or potential conflicts of interest . All author and peer review er disclosure information is provided in Appendix A and Appendix B. In writing a consensus document , it is recognized that consensus does not mean that there was complete agreement among all the writing group members . Surveys of the entire writing group were used to identify areas of consensus concerning performance of AF ablation procedures and to develop recommendations concerning the indications for catheter and surgical AF ablation . These recommendations were systematic ally balloted by the 60 writing group members and were approved by a minimum of 80 % of these members . The recommendations were also subject to a 1-month public comment period . Each partnering and collaborating organization then officially review ed , commented on , edited , and endorsed the final document and recommendations . The grading system for indication of class of evidence level was adapted based on that used by the ACC and the AHA.3,4 It is important to state , however , that this document is not a guideline . The indications for catheter and surgical ablation of AF , as well as recommendations for procedure performance , are presented with a Class and Level of Evidence ( LOE ) to be consistent with what the reader is familiar with seeing in guideline statements . A Class I recommendation means that the benefits of the AF ablation procedure markedly exceed the risks , and that AF ablation should be performed ; a Class IIa recommendation means that the benefits of an AF ablation procedure exceed the risks , and that it is reasonable to perform AF ablation ; a Class IIb recommendation means that the benefit of AF ablation is greater or equal to the risks , and that AF ablation may be considered ; and a Class III recommendation means that AF ablation is of no proven benefit and is not recommended . The writing group review ed and ranked evidence supporting current recommendations with the weight of evidence ranked as Level A if the data were derived from high- quality evidence from more than one r and omized clinical trial , meta-analyses of high- quality r and omized clinical trials , or one or more r and omized clinical trials corroborated by high- quality registry studies . The writing group ranked available evidence as Level B-R when there was moderate- quality evidence from one or more r and omized clinical trials , or meta-analyses of moderate- quality r and omized clinical trials . Level B-NR was used to denote moderate- quality evidence from one or more well- design ed , well-executed nonr and omized studies , observational studies , or registry studies . This design ation was also used to denote moderate- quality evidence from meta-analyses of such studies . Evidence was ranked as Level C-LD when the primary source of the recommendation was r and omized or nonr and omized observational or registry studies with limitations of design or execution , meta-analyses of such studies , or physiological or mechanistic studies of human subjects . Level C-EO was defined as expert opinion based on the clinical experience of the writing group . Despite a large number of authors , the participation of several societies and professional organizations , and the attempts of the group to reflect the current knowledge in the field adequately , this document is not intended as a guideline . Rather , the group would like to refer to the current guidelines on AF management for the purpose of guiding overall AF management strategies.5,6 This consensus document is specifically focused on catheter and surgical ablation of AF , and summarizes the opinion of the writing group members based on an extensive literature review as well as their own experience . It is directed to all health care professionals who are involved in the care of patients with AF , particularly those who are caring for patients who are undergoing , or are being considered for , catheter or surgical ablation procedures for AF , and those involved in research in the field of AF ablation . This statement is not intended to recommend or promote catheter or surgical ablation of AF . Rather , the ultimate judgment regarding care of a particular patient must be made by the health care provider and the patient in light of all the circumstances presented by that patient . The main objective of this document is to improve patient care by providing a foundation of knowledge for those involved with catheter ablation of AF . A second major objective is to provide recommendations for design ing clinical trials and reporting outcomes of clinical trials of AF ablation . It is recognized that this field continues to evolve rapidly . As this document was being prepared , further clinical trials of catheter and surgical ablation of AF were under way These guidelines up date previous guidance published in 2005 . They have been revised by a group who are members of the UK and Irel and Neuroendocrine Tumour Society with endorsement from the clinical committees of the British Society of Gastroenterology , the Society for Endocrinology , the Association of Surgeons of Great Britain and Irel and ( and its Surgical Specialty Associations ) , the British Society of Gastrointestinal and Abdominal Radiology and others . The authors hip represents leaders of the various groups in the UK and Irel and Neuroendocrine Tumour Society , but a large amount of work has been carried out by other specialists , many of whom attended a guidelines conference in May 2009 . We have attempted to represent this work in the acknowledgements section . Over the past few years , there have been advances in the management of neuroendocrine tumours , which have included clearer characterisation , more specific and therapeutically relevant diagnosis , and improved treatments . However , there remain few r and omised trials in the field and the disease is uncommon , hence all evidence must be considered weak in comparison with other more common cancers . Study Design . Clinical practice guideline . Objective . To develop evidence -based recommendations on use of interventional diagnostic tests and therapies , surgeries , and interdisciplinary rehabilitation for low back pain of any duration , with or without leg pain . Summary of Background Data . Management of patients with persistent and disabling low back pain remains a clinical challenge . A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing , but in some cases their utility remains uncertain or controversial . Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain . Methods . A multidisciplinary panel was convened by the American Pain Society . Its recommendations were based on a systematic review that focused on evidence from r and omized controlled trials . Recommendations were grade d using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations , Assessment , Development , and Evaluation Working Group . Results . Investigators review ed 3348 abstract s. A total of 161 r and omized trials were deemed relevant to the recommendations in this guideline . The panel developed a total of 8 recommendations . Conclusion . Recommendations on use of interventional diagnostic tests and therapies , surgery , and interdisciplinary rehabilitation are presented . Due to important trade-offs between potential benefits , harms , costs , and burdens of alternative therapies , shared decision-making is an important component of a number of the recommendations d c p B s i R This is one of a series of statements discussing the use of GI endoscopy in common clinical situations . The St and ards of Practice Committee of the American Society for Gastrointestinal Endoscopy ( ASGE ) prepared this text . In preparing this guideline , a search of the medical literature was performed by using PubMed . Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants . When few or no data exist from well- design ed prospect i ve trials , emphasis is given to results from large series and reports from recognized experts . Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time that the guidelines are drafted . Further controlled clinical studies may be needed to clarify aspects of this guideline . This guideline may be revised as necessary to account for changes in technology , new data , or other aspects of clinical practice . The recommendations are based on review ed studies and are grade d on the strength of the supporting evidence 1 ( Table 1 ) . he strength of individual recommendations is based on oth the aggregate evidence quality and an assessment of the nticipated benefits and harms . Weaker recommendations re indicated by phrases such as “ We suggest . . . , ” whereas tronger recommendations are typically stated as “ We recmmend . . . . ” This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients . This guideline is not a rule and should not be construed as establishing a legal st and ard of care or as encouraging , advocating , requiring , or discouraging any particular treatment . Clinical decisions in any particular case involve a complex analysis of the patient ’s condition and available courses of action . Therefore , clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines There is limited evidence on the association between adherence to guidelines for cancer survivors and health-related quality of life ( HRQoL ) . In a cross-sectional study of Korean breast cancer survivors , we examined whether adherence to the guidelines of the American Cancer Society ( ACS ) and World Cancer Research Fund/American Institute for Cancer Research ( WCRF/AICR ) for cancer survivors was related to levels of HRQoL , assessed by the Korean version of Core 30 ( C30 ) and Breast cancer module 23 ( BR23 ) of the European Organization for Research and Treatment of Cancer- Quality of Life Question naire ( EORTC-QLQ ) . We included a total of 160 women aged 21 to 79 years who had been diagnosed with breast cancer according to American Joint Committee on Cancer ( AJCC ) stages I to III and had breast cancer surgery at least six months before the interview . Increasing adherence to ACS guidelines was associated with higher scores of social functioning ( p for trend = 0.05 ) , whereas increasing adherence to WCRF/AICR recommendations was associated with higher scores of arm symptoms ( p for trend = 0.01 ) . These associations were limited to those with stage II or III cancer . Diet may be an important factor in relation to quality of life among Korean breast cancer survivors , however our findings warrant further prospect i ve studies to evaluate whether healthy diet improves survivors ’ quality of life DESCRIPTION The American College of Physicians ( ACP ) developed this guideline to present the evidence and provide clinical recommendations on the management of chronic insomnia disorder in adults . METHODS This guideline is based on a systematic review of r and omized , controlled trials published in English from 2004 through September 2015 . Evaluated outcomes included global outcomes assessed by question naires , patient-reported sleep outcomes , and harms . The target audience for this guideline includes all clinicians , and the target patient population includes adults with chronic insomnia disorder . This guideline grade s the evidence and recommendations by using the ACP grading system , which is based on the GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) approach . RECOMMENDATION 1 ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia ( CBT-I ) as the initial treatment for chronic insomnia disorder . ( Grade : strong recommendation , moderate- quality evidence ) . RECOMMENDATION 2 ACP recommends that clinicians use a shared decision-making approach , including a discussion of the benefits , harms , and costs of short-term use of medications , to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia ( CBT-I ) alone was unsuccessful . ( Grade : weak recommendation , low- quality evidence )
In the third-line setting , for patients who have not received erlotinib or gefitinib , treatment with erlotinib is recommended .
There are insufficient data to recommend routine third-line cytotoxic therapy .
Purpose To provide evidence -based recommendations to up date the American Society of Clinical Oncology guideline on systemic therapy for stage IV non – small-cell lung cancer ( NSCLC ) .
Results This guideline up date reflects changes in evidence since the previous guideline .