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Guideline Summary
Guideline Title
American Society of Clinical Oncology clinical practice guideline on uses of serum tumor markers in adult males with germ cell tumors.
Bibliographic Source(s)
Gilligan TD, Seidenfeld J, Basch EM, Einhorn LH, Fancher T, Smith DC, Stephenson AJ, Vaughn DJ, Cosby R, Hayes DF. American Society of Clinical Oncology clinical practice guideline on uses of serum tumor markers in adult males with germ cell tumors. J Clin Oncol. 2010 Jul 10;28(20):3388-404. [183 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

American Society of Clinical Oncology (ASCO) guidelines are normally updated every 3 years. At annual intervals, the Panel co-chairs and two Panel members designated by the co-chairs will determine the need for revisions to the guidelines on the basis of an examination of current literature.

Scope

Disease/Condition(s)

Germ cell tumors, including:

  • Nonseminomatous germ cell tumors (NSGCTs)
  • Seminomas
Guideline Category
Diagnosis
Evaluation
Risk Assessment
Screening
Clinical Specialty
Oncology
Urology
Intended Users
Physicians
Guideline Objective(s)

To provide recommendations on appropriate uses for serum markers of germ cell tumors (GCTs)

Target Population

Adult males with suspected or confirmed germ cell tumors

Interventions and Practices Considered

Diagnosis

  1. Serum tumor marker blood tests before diagnostic orchiectomy
    • Serum alpha-fetoprotein (AFP)
    • Serum human chorionic gonadotropin (hCG)
  2. Serum tumor marker blood tests for screening asymptomatic adults and diagnosing patients with cancers of unknown primary (CUP) (considered but not recommended)
  3. Serum tumor marker blood tests in patients presenting with metastasis and a primary tumor in testis, retroperitoneum, or anterior mediastinum
    • Serum alpha-fetoprotein (AFP)
    • Serum human chorionic gonadotropin (hCG)

Management/Treatment

Nonseminomatous Germ Cell Tumors (NSGCTs)

  1. For staging and prognosis before chemotherapy and/or additional surgery
    • Serum AFP
    • Serum human chorionic gonadotropin (hCG)
    • Serum lactate dehydrogenase (LDH)
  2. To predict response to or benefit from treatment
    • Assessment of false-positive marker elevations
    • Measurement of AFP, hCG, and LDH before chemotherapy begins for those with mediastinal or retroperitoneal NSGCTs
  3. To monitor response or progression during or soon after therapy
    • Measurement of AFP and/or hCG levels at the start of each chemotherapy cycle and again when chemotherapy concludes
  4. Surveillance after presumably definitive therapy
    • Measurement of AFP and hCG at each visit during surveillance after definitive therapy for NSGCT, regardless of stage

Seminoma

  1. For staging and prognosis before retroperitoneal lymph node dissection (RPLND), radiation, or chemotherapy measuring postorchiectomy serum concentrations of hCG and/or LDH for patients with testicular pure seminoma and preorchiectomy elevations.
  2. To guide treatment decisions for seminoma or to monitor response or progression of seminomas during treatment (considered but not recommended)
  3. For surveillance after presumably definitive therapy in advanced seminoma (not recommended for stage 1 seminoma)
Major Outcomes Considered
  • Recurrence rate
  • Site and time of relapse
  • Morbidity and mortality
  • Quality of life

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Literature Search Strategy

The systematic review for this guideline was conducted in collaboration with Cancer Care Ontario's Program in Evidence-Based Care (PEBC). The MEDLINE and EMBASE databases were searched for relevant evidence published from 1990 through the end of 2008. Electronic searches were limited to articles published after 1990 since practice patterns (e.g., risk stratification) and chemotherapy regimens changed substantially in the 1980s, making studies published before 1990 less relevant to current patient management and treatment decisions. Search terms included "germ cell tumors," "alpha-fetoprotein," "human chorionic gonadotropin," "lactate dehydrogenase," "cancer of unknown primary," and "testicular mass." Appendices B1 and B2 in the original guideline document show the specific search strategy used with each database. Other germ cell tumor (GCT) markers were omitted from the search since Panel members agreed early in their deliberations that evidence was unavailable to support routine use of any others. One reviewer selected articles for full-copy retrieval, and those sources' reference lists were searched for other relevant reports. Panel members provided additional references from personal files, particularly on points for which electronic searches failed to identify any relevant evidence. In these instances, studies published before 1990 were not excluded.

Inclusion and Exclusion Criteria

Articles were selected for inclusion in the systematic review if they were fully published English language reports of GCT marker assay results (alpha-fetoprotein [AFP], human chorionic gonadotropin [hCG], and/or lactate dehydrogenase [LDH]) and outcomes for adult human patients from randomized controlled trials (RCTs), systematic reviews of RCTs, meta-analyses, clinical practice guidelines, prospective or retrospective cohort studies, case-control studies, or case series. Meeting abstracts, letters, commentaries, editorials, case reports, nonsystematic (narrative) reviews, studies with sample sizes smaller than 50 patients, and studies limited to pediatric GCTs were excluded. Studies also were excluded if marker assay results and outcomes for patients with seminoma were not reported separately from results and outcomes for those with nonseminomatous germ cell tumor (NSGCT). Exclusion for sample sizes smaller than 50 patients did not apply to references provided by Panel members from personal files when electronic searches failed to identify any other relevant evidence.

Number of Source Documents

82 articles were included for data extraction. Figure 1 in the original guideline document presents the details of the exclusions and inclusions of publications identified for this systematic review.

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Data Extraction

Primary outcome measures of interest included overall survival (OS), disease-specific survival (DSS), disease free survival (DFS), relapse-free survival (RFS), event-free survival (EFS), and progression-free survival (PFS), treatment-related toxicities, quality of life, and cost effectiveness of care. Secondary outcomes or data elements of interest included the proportion of patients with marker elevations, results of univariate and/or multivariate analyses of marker elevations as prognostic factors, rates of concordance and discordance between different markers in the same patients, and assay performance characteristics (sensitivity, specificity, and positive and negative predictive values). Data were extracted directly into evidence tables (Data Supplement Tables DS1-DS13 see 'Availability of Companion Documents' field) by one reviewer and checked for accuracy by a second reviewer. Disagreements were resolved by discussion and by consultation with Panel co-chairs if necessary.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The American Society of Clinical Oncology (ASCO) Clinical Practice Guidelines Committee convened an Expert Panel (referred to as the Panel) consisting of experts in clinical medicine and research methods relevant to serum tumor marker (STM) use in diagnosis and management of patients with germ cell tumors (GCTs). The experts' fields included medical oncology, urology, development and use of tumor marker assays, health services research, epidemiology, and biostatistics. The Panel also included a patient representative.

The entire Panel met once to review results of the systematic review and formulate guideline recommendations; additional work was completed by electronic review of drafts. All members of the Panel participated in preparation and review of the draft guideline document.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

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

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The guideline was submitted to Journal of Clinical Oncology for peer review. Feedback was also solicited from external reviewers. The content of the guideline and the manuscript were reviewed and approved by the American Society of Clinical Oncology's Clinical Practice Guidelines Committee and by the Board of Directors before publication.

Recommendations

Major Recommendations

The recommendations are summarized in Table 3 in the original guideline document. Recommendations are organized as follows: those on markers for screening begin with "1," those on markers for diagnosis begin with "2," those labeled "3" address markers measured during treatment, and those labeled "4" address markers for surveillance after presumably definitive therapy. Additionally, Part I addresses questions 3 and 4 for nonseminomatous germ cell tumors (NSGCTs), while Part II addresses the same questions for seminoma.

Serum Tumor Markers (STMs) to Screen for Germ Cell Tumors (GCTs)

1. Clinical question: Are STM assays indicated to screen asymptomatic adults without current or prior clinical findings suggestive of GCT?

Recommendation 1. The Panel recommends against the use of STM assays to screen asymptomatic adults for GCTs because there is no evidence to support screening for GCTs with any blood test.

STMs to Diagnose GCTs

2. Clinical question: In the following circumstances, are STM assays indicated to diagnose adults clinically suspected to have GCTs:

2A. To help determine need for orchiectomy in patients with a testis abnormality?

Recommendation 2A. The Panel recommends that all patients suspected of having a testicular GCT have blood drawn for measurement of serum alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) before diagnostic orchiectomy to assist in establishing the diagnosis and to help interpret postorchiectomy tumor marker levels. However, the Panel recommends against using results of STM assays to guide decision making about whether or not to perform a diagnostic orchiectomy, since there is no evidence indicating that STM assay results predict or improve outcomes of these decisions. STM concentrations in the normal range do not rule out testicular neoplasm or the need for diagnostic orchiectomy. A significantly elevated serum AFP can establish the diagnosis of a mixed GCT in a patient whose histopathologic diagnosis is pure seminoma because seminomas do not produce AFP. However, borderline elevated values should be interpreted cautiously.

2B. To evaluate cancers of unknown primary (CUP) possibly derived from GCT?

Recommendation 2B. The Panel recommends against using serum AFP and hCG assay results to guide treatment for patients with CUP and indeterminate histology because evidence is lacking to support this use. Patients presenting with undifferentiated carcinoma in the midline should be considered for treatment with a chemotherapy regimen for disseminated GCTs, even if serum hCG and AFP concentrations are within the normal ranges.

2C. To evaluate patients presenting with metastatic disease and evidence of a testicular, retroperitoneal, or anterior mediastinal primary tumor?

Recommendation 2C. In rare patients who present with a testicular, retroperitoneal, or anterior mediastinal primary tumor and whose disease burden has resulted in an urgent need to start treatment, substantially elevated serum AFP and/or hCG may be considered sufficient for diagnosis of GCT. For such rare, medically unstable patients, treatment need not be delayed until histology results permit a tissue diagnosis.

Part 1: Nonseminomatous Germ Cell Tumor (NSGCT)

STMs During Treatment

I-3. Clinical question: In adult patients undergoing treatment (or observation) for NSGCT (postorchiectomy, for those with testicular tumors), are STM assays indicated for the following uses:

I-3A. To stage patients and predict prognosis before chemotherapy and/or additional surgery?

Recommendation I-3A-1. Although direct evidence is lacking to determine whether decisions based on STM assay results improve survival or other health outcomes for these patients when compared with decisions without assay results, the Panel recommends measuring serum AFP, hCG, and lactate dehydrogenase [LDH]) after orchiectomy and before any subsequent treatment for all patients with testicular NSGCT. The magnitude of STM elevations after orchiectomy influences risk stratification and treatment decisions, but levels must be interpreted appropriately, paying particular attention to conditions that may cause false-positive elevations. Serial STM measurements may be needed to determine whether STM levels are rising or falling and, if falling, whether the decline approximates the marker's biologic half-life (24-36 hours for hCG and 7 days for AFP; see Background on STMs for GCTs and Tables 1 and 2 in the original guideline document).

The Panel recommends caution with interpreting marker results (see Background on STMs for GCTs and Table 2 in the original guideline document for more complete information on possible causes and management of false-positive results).

Recommendation I-3A-2. Although direct evidence is lacking to demonstrate that decisions based on STM assay results improve survival or other health outcomes for these patients when compared with decisions made without assay results, the Panel recommends measuring serum AFP, hCG, and LDH before chemotherapy begins for patients with mediastinal or retroperitoneal NSGCTs to stratify risk and guide treatment.

I-3B. To predict response to or benefit from treatment?

Recommendation I-3B-1. The Panel recommends measuring serum AFP and hCG shortly before retroperitoneal lymph node dissection (RPLND) in patients with clinical stage I or II NSGCT. Those with rising or persistently elevated serum AFP or hCG are beyond stages IA or IB and require systemic therapy similar to the regimens used for patients with stage III disease.

Recommendation I-3B-2. Although direct evidence is lacking to determine whether decisions based on STM assay results improve survival or other health outcomes when compared with decisions made without assay results, the Panel recommends measuring hCG, AFP, and LDH immediately before chemotherapy for stage II or III testicular NSGCTs. The magnitude of marker elevations guides choice of chemotherapy regimen and treatment duration.

I-3C. To monitor treatment response or progression during or soon after therapy?

Recommendation I-3C. Although direct evidence is lacking to determine whether monitoring treatment response with STM assays during chemotherapy for patients with NSGCTs improves their survival or other health outcomes, the Panel recommends measuring serum AFP and hCG at the start of each chemotherapy cycle and again when chemotherapy concludes. However, the Panel sees no indication to delay the start of chemotherapy until after results of STM assays are known. Rising levels of AFP and/or hCG during chemotherapy usually imply progressive disease, indicating failure of the treatment and the need to change regimens. However, tumor lysis from chemotherapy, particularly during the first cycle, may result in a transient spike in AFP and/or hCG levels, and such a spike does not represent treatment failure. Continuing increases after chemotherapy predict lack of benefit from RPLND and indicate the need for salvage therapy. However, the Panel also recommends that patients whose AFP and hCG levels have normalized and who have resectable residual mass(es) following chemotherapy should undergo resection of all residual disease. While slow marker decline during chemotherapy conveys a higher risk of treatment failure, it does not indicate a need to change therapy. Persistently elevated but slowly declining markers soon after chemotherapy do not indicate an immediate need for additional chemotherapy; resection of residual tumor need not be delayed until they normalize.

STMs for Surveillance of Definitively Treated NSGCT

I-4. Clinical question: In adult patients with NSGCT, are STM assays indicated after presumably definitive therapy for surveillance and routine monitoring to detect asymptomatic recurrence?

Recommendation I-4. Although direct evidence is unavailable to determine whether monitoring STM concentrations during surveillance and following definitive therapy for NSGCT improves patients' survival or other health outcomes, the Panel recommends measuring AFP and hCG at each visit regardless of stage. Since evidence also is lacking to directly compare outcomes for different monitoring intervals or durations, the Panel recommends using intervals within the range used in the available uncontrolled series: every 1 to 2 months in the first year, every 2 to 4 months in the second year, every 3 to 6 months in the third and fourth years, every 6 months in the fifth year, and annually thereafter. The Panel also recommends that surveillance should continue for at least 10 years after therapy is completed.

Part II: Seminoma

STMs During Seminoma Treatment

II-3. Clinical question: In adult patients with pure seminoma undergoing treatment (or observation), are STM assays indicated for the following uses?

II-3A. To stage patients and predict prognosis before RPLND, radiation therapy, or chemotherapy?

Recommendation II-3A. Although direct evidence is lacking to determine whether measuring STM concentrations improves survival or other health outcomes of these patients, the Panel recommends measuring postorchiectomy serum concentrations of hCG and LDH for patients with testicular pure seminoma and preorchiectomy elevations because persistently elevated or rising concentrations may indicate metastatic disease and warrant a thorough work-up. However, the Panel recommends against using postorchiectomy serum concentrations of either hCG or LDH to stage or predict prognosis of patients with seminoma and involved nodes and/or metastatic disease.

II-3B. To predict response to or benefit from therapy?

Recommendation II-3B. The Panel recommends against using hCG or LDH concentrations to guide treatment decisions for patients with pure seminoma. Conclusive evidence is lacking that selecting therapy based on tumor marker levels yields better outcomes.

II-3C. To monitor treatment response or progression during or immediately after therapy?

Recommendation II-3C. The Panel recommends against using STMs to monitor treatment response of seminomas. However, the Panel recommends measuring hCG and AFP when treatment concludes. Rising tumor markers soon after therapy usually indicate progressive disease and thus mandate a thorough work-up to confirm or rule out the need for salvage therapy (usually chemotherapy).

STMs for Surveillance of Definitively Treated Seminoma

II-4. Clinical question: In adult patients with seminoma, are STM assays indicated after presumably definitive therapy for surveillance and routine monitoring to detect asymptomatic recurrence?

Recommendation II-4. Conclusive evidence is lacking for clinical utility of STMs in post-treatment surveillance of stage I seminoma, and the Panel recommends against this use. However, while direct evidence is unavailable to determine whether monitoring STM concentrations improves survival or other health outcomes of patients who have completed therapy for advanced seminoma, rising tumor markers maybe the earliest sign of relapse, and the Panel recommends measuring STMs at each visit for these patients. Since evidence also is lacking to directly compare outcomes for different monitoring intervals or durations, the Panel recommends using intervals within the range used in the available uncontrolled series: every 2 to 4 months in the first year, every 3 to 4 months in the second year, every 4 to 6 months in the third and fourth years, and annually thereafter. The Panel also recommends that surveillance should continue for at least 10 years after therapy is completed.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The recommendations are based primarily on published randomized trials. Refer to the "Literature review and analysis" sections of the original guideline document for specific evidence for each recommendation.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate use of serum tumor markers in adult males with germ cell tumors

Potential Harms

False-positive test results (see Table 2 in the original guideline document for causes of false-positive test results for serum tumor markers)

Qualifying Statements

Qualifying Statements

The American Society of Clinical Oncology's (ASCO's) practice guidelines 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 to identify questions and settings for further research. Because of the rapid flow of scientific information in oncology, new evidence may have emerged since the time a guideline was submitted for publication. Guidelines are not continually updated and may not reflect the most recent evidence. Guidelines address only the topics specifically identified in the guideline and are not applicable to interventions, diseases, or stages of disease not specifically identified. Guidelines cannot account for individual variation among patients and cannot 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 guideline is voluntary, with the ultimate determination regarding its application to be made by the physician in light of each patient's individual circumstances. ASCO guidelines describe the use of procedures and therapies in clinical practice and cannot 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 guidelines, or for any errors or omissions.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Patient Resources
Resources
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Gilligan TD, Seidenfeld J, Basch EM, Einhorn LH, Fancher T, Smith DC, Stephenson AJ, Vaughn DJ, Cosby R, Hayes DF. American Society of Clinical Oncology clinical practice guideline on uses of serum tumor markers in adult males with germ cell tumors. J Clin Oncol. 2010 Jul 10;28(20):3388-404. [183 references] PubMed External Web Site Policy
Adaptation

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

Date Released
2010 Mar
Guideline Developer(s)
American Society of Clinical Oncology - Medical Specialty Society
Source(s) of Funding

American Society of Clinical Oncology (ASCO)

Guideline Committee

American Society of Clinical Oncology (ASCO) Tumor Markers Expert Panel

Composition of Group That Authored the Guideline

Authors: Timothy D. Gilligan, Jerome Seidenfeld, Ethan M. Basch, Lawrence H. Einhorn, Timothy Fancher, David C. Smith, Andrew J. Stephenson, David J. Vaughn, Roxanne Cosby, and Daniel F. Hayes

Expert Panel Members: Timothy Gilligan, MD, co-chair, Taussig Cancer Institute, Cleveland Clinic; Daniel F. Hayes, MD, co-chair, University of Michigan Medical Center; Timothy Fancher, Patient Representative; Lawrence H. Einhorn, MD, Indiana Cancer Pavilion, Indiana University; David C. Smith, University of Michigan Medical Center; Andrew J Stephenson, MD, Glickman Urological and Kidney Institute, Cleveland Clinic; David J. Vaughn, MD, Abramson Cancer Center, University of Pennsylvania; Ethan M. Basch, MD, Clinical Practice Guidelines Committee Liaison, Memorial Sloan-Kettering Cancer Center

Financial Disclosures/Conflicts of Interest

Guideline and Conflicts of Interest

The Expert Panel was assembled in accordance with American Society of Clinical Oncology's (ASCO's) Conflict of Interest Management Procedures for Clinical Practice Guidelines ("Procedures," summarized at www.asco.org/guidelinescoi External Web Site Policy). Members completed ASCO's disclosure form, which requires disclosure of financial and other interests relevant to the subject matter of the guideline, including relationships with commercial entities that are reasonably likely to experience direct regulatory or commercial impact as the result of promulgation of the guideline. Categories for disclosure include employment relationships, consulting arrangements, stock ownership, honoraria, research funding, and expert testimony. In accordance with the Procedures, the majority of the members of the Panel did not disclose any such relationships.

Although all authors completed the disclosure declaration, the following author(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a "U" are those for which no compensation was received; those relationships marked with a "C" were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.

Employment or Leadership Position: None

Consultant or Advisory Role: Daniel F. Hayes, Incyte (C), DNA Repair (C), Compendia Bioscience (C), Chugai Pharmaceuticals (C)

Stock Ownership: Lawrence H. Einhorn, Amgen, Biogen Idec, GlaxoSmithKline; Daniel F. Hayes, Oncimmune, Halcyon Diagnostics

Honoraria: Daniel F. Hayes, Pfizer, GlaxoSmithKline

Research Funding: Daniel F. Hayes, AstraZeneca, GlaxoSmithKline, Novartis, Pfizer, Wyeth-Ayerst Genetics Institute, Veridex

Expert Testimony: None

Other Remuneration: None

Guideline Status

This is the current release of the guideline.

American Society of Clinical Oncology (ASCO) guidelines are normally updated every 3 years. At annual intervals, the Panel co-chairs and two Panel members designated by the co-chairs will determine the need for revisions to the guidelines on the basis of an examination of current literature.

Guideline Availability

Electronic copies: Available from the American Society of Clinical Oncology (ASCO) Web site External Web Site Policy.

Print copies: Available from American Society of Clinical Oncology, Health Services Research, 1900 Duke Street, Suite 200, Alexandria, VA 22314.

Availability of Companion Documents

The following are available:

  • American Society of Clinical Oncology (ASCO) clinical practice guideline on uses of serum tumor markers in adult males with germ cell tumors. Slide set. 2010. 32 p. Electronic copies: Available in Portable Document Format (PDF) External Web Site Policy and Power Point External Web Site Policy from the American Society of Clinical Oncology (ASCO) Web site.
  • ASCO clinical practice guideline on uses of serum tumor markers in adult males with germ cell tumors Journal of Oncology Practice (JOP) guideline summary. Guideline summary. Electronic copies: Available in Portable Document Format (PDF) from the ASCO Web site External Web Site Policy.
  • Germ cell markers by tumor type table. 2010. 2 p. Electronic copies: Available from the American Society of Clinical Oncology (ASCO) Web site External Web Site Policy.
Patient Resources

The following is available:

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

NGC Status

This NGC summary was completed by ECRI Institute on October 6, 2010.

Copyright Statement

This summary is based on the original guideline, which is subject to the American Society of Clinical Oncology's copyright restrictions.

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