Methodology for Development of Guidelines for Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

doi:10.1378/chest.12-2344

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Volume 143, Issue 5, Supplement, May 2013, Pages 41S-50S

https://doi.org/10.1378/chest.12-2344 Get rights and content

Background

The objective was to develop high-quality and comprehensive evidence-based guidelines on the diagnosis and management of lung cancer.

Methods

A carefully crafted panel of lung cancer experts, methodologists, and other specialists was assembled and reviewed for relevant conflicts of interest. The American College of Chest Physicians guideline methodology was used. Population, intervention, comparator, outcome (PICO)-based key questions and defined criteria for eligible studies were developed to inform the search strategies, subsequent evidence summaries, and recommendations. Research studies, systematic reviews, and meta-analyses, where they existed, were assessed for quality and summarized to inform the recommendations.

Results

Each recommendation was developed with supporting evidence and the consensus of the writing committees. Controversial recommendations were identified for further consultation by the entire panel, with anonymous voting to achieve consensus.

Conclusions

The final recommendations can be trusted by health-care providers, patients, and other stakeholders since they are based on the current evidence in these areas and were developed with trustworthy processes for guideline development.

Section snippets

Target Audience

The main objective of these guidelines is to inform the clinical decisions that must be jointly made by physicians and patients in developing diagnostic, treatment, and management plans so that they can enhance the benefits and reduce the harms associated with various options. Thus, the main audiences for these guidelines include both patients and physicians. Comprehensive guidelines such as these are intended for a multidisciplinary readership, including primary care, medical, and surgical

Scope

The breadth of these guidelines has also evolved over the three editions. With increasingly greater success in tobacco treatment approaches, the LC III Executive Committee determined that an entire article should be dedicated to helping physicians, nurses, and treatment counselors help their patients with lung cancer stop using tobacco.⁶ Staging lung cancer has become increasingly complex, so the previous differentiation between invasive and noninvasive staging, now more closely integrated,

Panel Composition and Responsibilities

A call for applications to serve on the LC III guidelines panel was put forth to the ACCP membership, to past panelists, and to other organizations that have previously endorsed earlier editions of these guidelines or appointed representatives to serve on those panels. Guiding the team was the LC III Executive Committee, composed of a Panel Chair, Vice Chair, Liaison to the Guidelines Oversight Committee (GOC), and two staff members, one serving as an adviser and the other as the lead

Defining the Research Questions and Search Strategies

Panelists received online training (R. L. Diekemper, MPH; J. Ornelas, PhD; S. Z. Lewis, PhD, Educational Program for Conducting an Evidence Review, unpublished data, 2011) in the more rigorous methodology used by the ACCP in recent years to conduct comprehensive and systematic evidence reviews, meta-analyses, and construction of evidence tables and evidence profiles. The topic editors and their committees then drafted the evidence questions using a PICO format whenever possible (patient

Formulating the Recommendations

In most cases the topic editors, along with the other completely nonconflicted members of the article committee, formulated the recommendations. The summarized evidence tables and profiles (where profiles existed) provided the foundation for the recommendations. In formulating the recommendations, panelists considered not only the body of evidence but also the balance between the benefits and harms and considerations of other factors, such as cost or resource availability considerations and

Dissemination and Implementation

These guidelines are widely disseminated through the CHEST journal publication, National Guidelines Clearinghouse, and Guidelines International Network library. Additional clinical resources will soon be available to users of CHEST Evidence, an upcoming tool for searching the content of ACCP guidelines. Patient education guides will be posted on The CHEST Foundation's OneBreath.org website.

As the expanding research into diagnostic techniques and treatment options continues to evolve, the

Conclusion

The third edition of the ACCP Lung Cancer Guidelines has been developed using a more explicit and transparent approach to a PICO-based evidence review, assessment of study quality, and evolution of evidence-based recommendations. Adherence to stricter standards for COI guided the composition of a panel at lower risk of introducing any biases into the process. The rigorous reviews ensured balanced and evidence-based results.

This is the last of the comprehensive ACCP Lung Cancer Guidelines that

Acknowledgments

Author contributions: Dr Lewis served as guarantor. The authors on this article all served as members of the LC III Executive Committee.

Dr Lewis: contributed to producing the first draft and was responsible for the final article.

Dr Addrizzo-Harris: contributed as the liaison to the Guidelines Oversight Committee and reviewed and approved the final article.

Ms Diekemper: contributed to sections related to her role as guideline methodologist and reviewed and approved the final article.

References (23)

WM Alberts
Introduction to the third edition: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2013)
FT Leone et al.
Treatment of tobacco use in lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2013)
GA Silvestri et al.
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
Chest
(2013)
N Ramnath et al.
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
Chest
(2013)
FC Detterbeck et al.
The stage classification of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2013)
JP Wisnivesky et al.
Diagnosis and treatment of bronchial intraepithelial neoplasia and early lung cancer of the central airways: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2013)
JA Howington et al.
Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2013)
AD Oxman et al.
Validation of an index of the quality of review articles
J Clin Epidemiol
(1991)
G Guyatt et al.
Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians task force
Chest
(2006)
GH Guyatt et al.
Grades of recommendation for antithrombotic agents: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition)
Chest
(2008)

G Guyatt et al.

Addressing resource allocation issues in recommendations from clinical guideline panels: suggestions from an American College of Chest Physicians task force

Chest

(2006)

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Funding/Sponsors: The development of this guideline was supported primarily by the American College of Chest Physicians. The lung cancer guidelines conference was supported in part by a grant from the Lung Cancer Research Foundation. The publication and dissemination of the guidelines was supported in part by a 2009 independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.

COI grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.

Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://dx.doi.org/10.1378/chest.1435S1.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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Methodology for Development of Guidelines for Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Background

Methods

Results

Conclusions

Section snippets

Target Audience

Scope

Panel Composition and Responsibilities

Defining the Research Questions and Search Strategies

Formulating the Recommendations

Dissemination and Implementation

Conclusion

Acknowledgments

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J Clin Epidemiol

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