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Guideline Summary
Guideline Title
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.
Bibliographic Source(s)
Deng GE, Rausch SM, Jones LW, Gulati A, Kumar NB, Greenlee H, Pietanza MC, Cassileth BR. 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. Chest. 2013 May;143(5 Suppl):e420S-36S. [159 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Cassileth BR, Deng GE, Gomez JE, Johnstone PA, Kumar N, Vickers AJ, American College of Chest Physicians. Complementary therapies and integrative oncology in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007 Sep;132(3 Suppl):340S-54S.

Scope

Disease/Condition(s)

Lung cancer

Guideline Category
Management
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Oncology
Pulmonary Medicine
Radiation Oncology
Thoracic Surgery
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Patients
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers
Guideline Objective(s)

To 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

Target Population

Patients with or at risk for lung cancer

Interventions and Practices Considered
  1. Counseling on the benefits and risks of complementary therapies
  2. Mind-body modalities (e.g., yoga)
  3. Massage therapy
  4. Supervised exercise-based pulmonary rehabilitation
  5. Acupuncture
  6. Nutrition (e.g., diet rich in non-starchy vegetables and fruits, lower meat consumption, addition of high calorie and protein supplements, oral nutritional supplementation)
Major Outcomes Considered
  • Reduction of physical and emotional symptoms
  • Quality of life
  • Survival

Methodology

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

In general, literature searches of major databases were carried out using keywords related to intervention modalities, symptom end points, cancer, or lung cancer. Searches were limited to meta-analyses, systematic reviews, and randomized controlled trials (RCTs). Narrative reviews and single-arm studies were excluded. There was no exclusion based on sample size. The resultant reference lists were searched manually to exclude entries that were obviously irrelevant to the topics. Specific search strategies are described below and full descriptions are available on request. The searches were structured around the following patient, intervention, comparison, outcomes (PICO) questions:

  1. In patients with lung cancer, do discussions about complementary therapies, their benefits, and risks improve the patients' understanding of how to take advantage of the therapies that are helpful and how to reduce exposure to potential harm?
  2. In patients with lung cancer experiencing symptoms, do mind-body modalities as part of a multidisciplinary approach help reduce anxiety, mood disturbance, pain, nausea, vomiting, and sleep disturbance?
  3. In patients with lung cancer whose anxiety or pain is not adequately controlled by usual care, does massage therapy help reduce the symptoms?
  4. In patients with lung cancer with compromised lung function awaiting or following surgical resection of lung lesions, does supervised exercise-based pulmonary rehabilitation improve cardiorespiratory fitness and functional capacity?
  5. In patients with lung cancer with compromised lung function and inoperable disease, does supervised exercise-based pulmonary rehabilitation improve cardiorespiratory fitness and functional capacity?
  6. In patients experiencing nausea and vomiting from chemotherapy or radiotherapy, does acupuncture as an adjunct treatment option reduce the symptoms?
  7. In patients with lung cancer whose cancer-related pain and peripheral neuropathy is not controlled adequately, does acupuncture as an adjunct treatment help reduce the symptoms?
  8. In people at risk of lung cancer, do certain dietary regimens help reduce the risk?
  9. In patients with lung cancer, does nutritional intake of protein-energy-dense foods beneficially affect nutritional status compared with usual care?
  10. In patients with lung cancer who have sarcopenia, does oral nutritional supplementation with n-3 fatty acids beneficially affect nutritional status compared with usual care with other nutritional supplements?

To investigate mind-body modalities in patients with lung cancer, a comprehensive literature review was conducted using Ovid MEDLINE, PubMed, and Web of Science (2000 to 2011) using the following Medical Subject Heading (MeSH) terms and text words: "lung cancer," "cancer meditation," "mind body," "yoga cancer," "hypnosis cancer," "visualization cancer," "relaxation cancer," "anxiety cancer," "dyspnea cancer," "fatigue cancer," and "depression cancer." Relevant reference lists were also searched manually. Studies exclusively involving adult patients with cancer that provided subjects with mind-body interventions were deemed eligible. Mind-body modalities were defined according to the National Institutes of Health/the National Center for Complementary and Alternative Medicine (NCCAM) definition: "Mind and body practices focus on the interactions among the brain, mind, body, and behavior, with the intent to use the mind to affect physical functioning and promote health." Many approaches embody this concept, and the panel included in their review interventions consisting of meditation/mindfulness-based stress reduction (MBSR); yoga; tai chi; qigong; and psychosocial, hypnosis, and mind-body relaxation techniques. Studies involving adult cancer were deemed eligible. Included studies could test the independent effects of the mind-body modality intervention. Studies with a participant mean age below 18 years or that were non-English were excluded.

To investigate massage therapy in patients with lung cancer, the PubMed database was searched from its beginning to December 2011, using the following search terms: ("massage" AND "depression" AND "cancer") OR ("massage" AND "anxiety" AND "cancer") for the effect of massage therapy on anxiety and depression; "massage"[ti] AND "pain" for the effect of massage therapy on pain; or "massage"[ti] AND "safety"[ti] for the safety of massage therapy. The research results were limited to "meta-analysis" or "reviews" and there was no language restriction.

To investigate exercise in patients with lung cancer, Ovid MEDLINE (1950-2011), PubMed (1966-2011), and Web of Science (1950-2011) were searched using the following MeSH terms and text words: "lung cancer," "non-small cell lung cancer," "thoracic malignancies," "exercise," "exercise therapy and exercise training," "aerobic training," "resistance training," and "rehabilitation." Relevant reference lists were also searched manually. Studies exclusively involving adult patients with histologically confirmed lung cancer who were provided with supervised exercise training programs were deemed eligible. Supervised exercise training was defined as interventions consisting of aerobic, resistance, or the combination of aerobic and resistance training as opposed to unsupervised or home-based interventions. Included studies could test the independent effects of exercise training or the effects of exercise training as part of a multidisciplinary rehabilitation program. Studies with a participant mean age below 18 years or that were non-English were excluded.

To investigate acupuncture in patients with lung cancer, Ovid MEDLINE (1950-2011), PubMed (1966-2011), Web of Science (2000-2011), and lists of related references in reviewed journal articles were searched using the following MeSH terms and text words: "lung cancer," "cancer," "thoracotomy," "acupuncture," "acupressure," "electro acupuncture," "auricular acupuncture," "nausea," "vomiting," "chemotherapy induced peripheral neuropathy," "cancer pain," "smoking cessation," "safety," and "efficacy." Relevant reference lists were also searched manually. Studies exclusively involving either pediatric or adult patients with a history of cancer who were provided with acupuncture or its variations for treatment were evaluated. Included studies involved using acupuncture as a treatment modality for nausea and vomiting, cancer pain, chemotherapy-induced peripheral neuropathy (CIPN), and smoking cessation; studies examining the safety of acupuncture were also included. Trials that were in non-English languages were included because a fair number of acupuncture studies are published in non-English journals. The abstracts were evaluated and this is specified in the review tables. The evaluations for pain and nausea were limited to patients who had a diagnosis of cancer.

To investigate nutrition in patients with lung cancer, Ovid MEDLINE (2005-2012) and PubMed (2005-2012) were searched using the following nested search terms and text words: "lung cancer," "non-small cell lung cancer," "thoracic malignancies and nutrition," "nutrition and lung cancer prevention," "nutritional therapy and lung cancer treatment," "nutritional management of lung cancer," and "nutrition and lung cancer survivorship." Relevant reference lists were also searched. Research involving adult patients over age 18, published in the English language or fully translated, including meta-analyses, epidemiologic studies of nutritional intake to prevent progression from high-risk histology to lung cancer, clinical trials testing specific individual or combination nutrients to improve prognosis and/or quality of life (QOL) or to alleviate symptoms of lung cancer treatment, and studies examining survivorship were included. The study population included the entire continuum of cancer, targeting individuals and populations at high risk of lung cancer and those with histologically confirmed lung cancer. Studies involving nutritional interventions for survivorship from lung cancer were also deemed eligible, but those with a participant mean age below 18 years or that were non-English were excluded.

Number of Source Documents

See the original guideline document for specific numbers of articles used to formulate recommendations for each topic.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Not Given)
Rating Scheme for the Strength of the Evidence

Not stated

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

Assessment of Study Quality

Systematic reviews and meta-analyses were assessed using Documentation and Appraisal Review Tool (DART) (R. L. Diekemper; B. K. Ireland, MD; and L. R. Merz, PhD, MPH, DART, unpublished data, 2012), which was developed as an improved alternative to the existing tools for use in a clinical setting. However, this tool has been adopted for use in American College of Chest Physicians (ACCP) guidelines and consensus statements since 2011.

Quality was assessed for each study as well as for the body of relevant evidence. Based on the population, intervention, comparator, and outcome (PICO) questions and volume of available literature, multiple study designs were included in the systematic reviews of the literature. Randomized controlled trials (RCTs) primarily indicate benefits, but whenever observational studies met inclusion criteria they were often helpful in identifying harms. Observational studies were also examined when RCTs were not available to answer a particular PICO question. Allowing for multiple study designs resulted in the need for multiple quality assessment tools. Tools were chosen for assessing RCTs, observational studies, and diagnostic studies. The quality assessment tool for RCTs (R. L. Diekemper, B. K. Ireland, and L. R. Merz, unpublished data, 2012) was used for assessing the quality of RCTs, and a tool developed by the committee of the ninth edition of the Antithrombotics Guidelines was used for assessing the quality of observational studies. Diagnostic studies were assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS).

Meta-analyses

If a recently published good-quality meta-analysis was available, then it was used to inform the recommendations. When a good-quality meta-analysis was not available, guideline authors were encouraged to perform their own meta-analyses. Meta-analyses were performed when the data were fairly homogeneous. If a study was deemed poor quality, then it was not included in the pooled analysis. Heterogeneity of the pooled results was assessed using a χ2 test and Higgins I2, and a forest plot was examined for consistency of the results. The random effects model was chosen a priori as the appropriate model for pooling the data because it accounts for heterogeneity among the included studies. Results from the meta-analyses are available in the supplementary materials that can be downloaded from the Journal website under the corresponding article in the table of contents.

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

Panel Composition and Responsibilities

A call for applications to serve on the 3rd edition of the American College of Chest Physicians (ACCP) Lung Cancer Guidelines (LC III) 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 methodologist. The GOC appointed the Liaison and the Chair, who was required to be free of conflicts of interest (COI). This Executive Committee provided general oversight and guidance; multiple reviews of research questions, article outlines, manuscripts, evidence tables, and other supporting documents; and facilitation of the final conference discussions and voting. As the scope was defined, content experts in each major area were identified to serve as topic editors and nominated by the Panel Chair to be advanced to the GOC for the requisite qualifications and COI review and approval process. These topic editors organized their research and writing teams, oversaw the work of the individual members, edited separate contributions into synthesized manuscripts, presented evidence at the final conference, and managed any of their committee members who were approved with management stipulations relevant to their COIs.

Each topic editor was initially charged with proposing individuals to support their topic committees with expertise in the content area and/or methodology. With the Chair's approval, these individuals were nominated for GOC reviews for COI and expertise. In some cases, GOC staff helped to locate additional methodologic support when it was determined to be necessary for various article committees. This resulted in an international panel of >100 multidisciplinary experts across 24 articles representing the fields of pulmonary medicine, critical care medicine, thoracic surgery, medical and radiation oncology, pathology, integrative medicine, primary care, health-care research, guidelines methodology, and epidemiology. Nineteen international organizations that are also dedicated to advancing research and practice in the area of lung cancer were invited to appoint representatives to this guideline project as adjunct participants. These individuals, unless already approved panelists, were not considered full voting members of the panel, since they had not been through the same ACCP COI review, but were included at the final conference, participated fully in the discussions, and provided external review and feedback on the manuscripts and supporting documentation.

Formulating the Recommendations

In most cases the topic editors, along with the other completely non-conflicted 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 patient values and preferences, which might vary widely for some recommendations. These additional considerations are described in a Remarks section, which appears just below the relevant recommendation in the publication, each time the recommendation appears.

Grading the Recommendations

Recommendations that are strong must be differentiated from those that are weak or weaker. Thus, the ACCP Grading System was used (see the "Rating Scheme for the Strength of the Recommendations" field), and the wording of the recommendations is explicit. This grading system has been used since 2005 and is based on two dimensions: the balance of benefits to harms and the quality of the evidence base. If the benefits clearly outweigh the harms or the harms clearly outweigh the benefits, the strength of the recommendation is considered strong and graded as a 1. In most cases, when there is strong confidence that the benefits outweigh the harms, most patients would choose the intervention endorsed in that recommendation. However, when the tradeoffs between desirable and undesirable consequences are not as clear, variability in patient preferences and values often becomes germane to the decision-making conversation.

Weak recommendations are those for which the benefits and harms are more equally balanced, and thus a clear choice is not as obvious; these are graded with a 2. Strong recommendations are phrased, "the panel recommends," whereas weak recommendations are phrased "the panel suggests." Accompanying these indications of the strength of a recommendation is a letter score (A, B, or C) representing the grading of the body of relevant literature.

In grading the quality of the evidence, RCTs start with a high score but might be downgraded to moderate or even low based on the following criteria: limitations in the study design or conduct of the trial, imprecision, indirectness relative to the specifics of the PICO question, inconsistency in the results, and risk of reporting bias. Observational studies, on the other hand, start off as low-level evidence but can be upgraded to moderate or even high if exceptionally large and consistent treatment effects increase confidence in the findings, especially if there is a strong dose-response gradient.

The final grades are combinations reflecting the strength of the recommendation and the quality of the evidence. Strong recommendations with high quality evidence, grade of 1A, are less common than in past editions of these guidelines, since the evidence is assessed with greater rigor for most topics, and few studies without important limitations are available.

However, recommendations that do attain this score are those for which the panel could state with confidence that new studies would be unlikely to change the direction of the effect. These recommendations apply to most patients in most circumstances. But as the grades decline, patient values and preferences likely would play an increasingly greater role in determining the best treatments or interventions for each patient.

The Final Conference

As the evidence reviews were completed and the tables and profiles prepared, the manuscripts and recommendations were drafted. Members of the article committees convened by phone or e-mail to discuss the evidence and work on drafting and grading the recommendations. These discussions generally resulted in agreement on both the quality of the evidence and strength of the recommendations.

The manuscripts and supporting tables were then reviewed by members of the Executive Committee and, after several iterations, the revised versions were shared among all panelists and the representatives of invited organizations in advance of the conference. The other panelists and representatives were asked not only to provide feedback but also to review the recommendations to identify any controversies. A recommendation was deemed to be controversial if at least one person disagreed with the wording or the grading, if there was controversy in practice, if there were wide variations in practice, or if at least one person asked that it be discussed among the broader panel and association representatives. These identified controversies composed the main agenda for the conference.

See the "Methodology for Development of Guidelines for Lung Cancer" (see the "Availability of Companion Documents" field) for more information.

Rating Scheme for the Strength of the Recommendations

Strength of the Recommendations Grading System

Grade of Recommendation Benefit vs. Risk and Burdens Methodologic Quality of Supporting Evidence Implications
Strong recommendation, high-quality evidence, Grade 1A Benefits clearly outweigh risk and burdens or vice versa Consistent evidence from randomized controlled trials (RCTs) without important limitations or exceptionally strong evidence from observational studies Recommendation can apply to most patients in most circumstances. Further research is very unlikely to change confidence in the estimate of effect
Strong recommendation, moderate-quality evidence, Grade 1B Benefits clearly outweigh risk and burdens or vice versa Evidence from RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence from observational studies Recommendation can apply to most patients in most circumstances. Higher quality research may well have an important impact on confidence in the estimate of effect and may change the estimate
Strong recommendation, low- or very-low-quality evidence, Grade 1C Benefits clearly outweigh risk and burdens or vice versa Evidence for at least one critical outcome from observational studies, case series, or from RCTs with serious flaws or indirect evidence Recommendation can apply to most patients in many circumstances. Higher-quality research is likely to have an important impact on confidence in the estimate of effect and may well change the estimate
Weak recommendation, high-quality evidence, Grade 2A Benefits closely balanced with risks and burden Consistent evidence from RCTs without important limitations or exceptionally strong evidence from observational studies The best action may differ depending on circumstances or patient's or societal values. Further research is very unlikely to change confidence in the estimate of effect
Weak recommendation, moderate-quality evidence, Grade 2B Benefits closely balanced with risks and burden Evidence from RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or very strong evidence from observational studies Best action may differ depending on circumstances or patient's or societal values. Higher-quality research may well have an important impact on confidence in the estimate of effect and may change the estimate
Weak recommendation, low- or very-low-quality evidence, Grade 2C Uncertainty in the estimates of benefits, risks, and burden; benefits, risk, and burden may be closely balanced Evidence for at least one critical outcome from observational studies, case series, or RCTs, with serious flaws or indirect evidence Other alternatives may be equally reasonable. Higher-quality research is likely to have an important impact on confidence in the estimate of effect and may well change the estimate
Cost Analysis

American College of Chest Physicians (ACCP) guidelines include consideration of resources in recommendations under selected circumstances. If it is likely that resource considerations would impact the direction or strength of a recommendation, a search for cost-effectiveness studies may have been conducted. Most recommendations in these guidelines do not include a full assessment of resource considerations. However, they can be adapted to middle- and low-income countries using the ADAPTE strategies.

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

Internal and External Peer Review

Once Executive Committee approval was received, the articles were submitted to American College of Chest Physicians (ACCP) staff for several layers of review. All reviewers were required to undergo a full conflict of interest (COI) appraisal before being approved. In the first round of reviews, the Thoracic Oncology NetWork reviewed the content of the manuscripts and the members of the Guidelines Oversight Committee (GOC) assessed the manuscripts for adherence to the methodology and conformance with the evidence. The ACCP President also appointed members of the Board of Regents to evaluate the guidelines in depth. All comments were collated into spreadsheets to ensure that they were appropriately answered. GOC and board reviewers discussed each comment and determined which should be mandatory for the authors to amend and which were provided as suggestions for improvement. All reviews and comments were anonymous, and authors were required to respond to all mandatory issues either by revising the manuscripts or providing written justification explaining why they did not agree with the reviewers' comments.

The revised manuscripts were submitted for round II review, simultaneously with the Journal peer review. Once the GOC and board reviewers approved the manuscripts, the ACCP President, President Elect, President Elect Designee, and Immediate Past President reviewed the guidelines. Approval was granted pending confirmation from the Board of Regents, before submission to the journal for final review by the Journal Editor. In addition to this extensive review process, which included nearly 30 individual reviewers from the ACCP leadership, external organizations were provided with opportunities to provide feedback before, during, and just after the conference. This final version was submitted for consideration for endorsement to all of the invited organizations, whether or not they sent representatives to the conference. However, once the guidelines were approved by the ACCP Board of Regents, no further changes were accepted. Organizations that provided endorsements are listed in each article.

Recommendations

Major Recommendations

The grades of recommendation (1A–2C) and the approach to rating the quality of evidence are defined at the end of the "Major Recommendations" field.

Usage of Complementary Therapies and Approaches in Addressing Patient's Needs

It is suggested that all lung cancer patients should be asked about their interest in and usage of complementary therapies. Counseling on the benefits and risks of those therapies should be provided (Grade 2C).

Mind-body Modalities

In lung cancer patients experiencing the symptoms, mind-body modalities are suggested as part of a multidisciplinary approach to reduce anxiety, mood disturbance, sleep disturbance, and improve quality of life (QOL) (Grade 2B).

In lung cancer patients experiencing the symptoms, mind-body modalities are suggested as part of a multidisciplinary approach to reduce acute or chronic pain (Grade 2B).

In lung cancer patients experiencing the symptoms, mind-body modalities are suggested as part of a multidisciplinary approach to reduce anticipatory chemotherapy-induced nausea and vomiting (Grade 2B).

In lung cancer patients experiencing the symptoms, yoga, a movement-based mind-body modality is suggested as part of a multidisciplinary approach to reduce fatigue and sleep disturbance while improving mood and QOL (Grade 2B).

Massage Therapy

In lung cancer patients whose anxiety or pain is not adequately controlled by usual care, addition of massage therapy performed by trained professionals is suggested as part of a multi-modality cancer supportive care program (Grade 2B).

Exercise

In patients awaiting pulmonary resection for suspected lung cancer with compromised lung function, supervised exercise-based pulmonary rehabilitation is suggested to improve cardiorespiratory fitness and functional capacity (Grade 2C).

In post-surgical lung cancer patients with compromised lung function, supervised exercise-based pulmonary rehabilitation is suggested to improve cardiorespiratory fitness and functional capacity (Grade 2C).

In advanced (inoperable) lung cancer patients receiving palliative anticancer therapy and compromised lung function, supervised exercise-based pulmonary rehabilitation is suggested to improve cardiorespiratory fitness and functional capacity (Grade 2C).

Acupuncture

In patients having nausea and vomiting from either chemotherapy or radiation therapy, acupuncture or related techniques is suggested as an adjunct treatment option (Grade 2B).

In patients with cancer related pain and peripheral neuropathy, acupuncture is suggested as an adjunct treatment in patients with inadequate control of symptoms (Grade 2C).

Nutrition

In people who might develop lung cancer a diet rich in non-starchy vegetables and fruits is suggested to reduce the risk of lung cancer (Grade 2C).

In people who might develop lung cancer, limiting the consumption of a large amount of red meat and processed meat is suggested; lower meat consumption may reduce the risk of lung cancer (Grade 2C).

In patients undergoing treatment of lung cancer who have experienced weight loss, the addition of high calorie and protein supplements (1.5 kcal/mL) as a nutritional adjunct is suggested to achieve weight stabilization (Grade 2C).

In patients with lung cancer who have sarcopenia, oral nutritional supplementation with n-3 fatty acids is suggested in order to improve the nutritional status (Grade 2C).

Definitions:

Strength of the Recommendations Grading System

Grade of Recommendation Benefit vs. Risk and Burdens Methodologic Quality of Supporting Evidence Implications
Strong recommendation, high-quality evidence, Grade 1A Benefits clearly outweigh risk and burdens or vice versa Consistent evidence from randomized controlled trials (RCTs) without important limitations or exceptionally strong evidence from observational studies Recommendation can apply to most patients in most circumstances. Further research is very unlikely to change confidence in the estimate of effect
Strong recommendation, moderate-quality evidence, Grade 1B Benefits clearly outweigh risk and burdens or vice versa Evidence from RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence from observational studies Recommendation can apply to most patients in most circumstances. Higher quality research may well have an important impact on confidence in the estimate of effect and may change the estimate
Strong recommendation, low- or very-low-quality evidence, Grade 1C Benefits clearly outweigh risk and burdens or vice versa Evidence for at least one critical outcome from observational studies, case series, or from RCTs with serious flaws or indirect evidence Recommendation can apply to most patients in many circumstances. Higher-quality research is likely to have an important impact on confidence in the estimate of effect and may well change the estimate
Weak recommendation, high-quality evidence, Grade 2A Benefits closely balanced with risks and burden Consistent evidence from RCTs without important limitations or exceptionally strong evidence from observational studies The best action may differ depending on circumstances or patient's or societal values. Further research is very unlikely to change confidence in the estimate of effect
Weak recommendation, moderate-quality evidence, Grade 2B Benefits closely balanced with risks and burden Evidence from RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or very strong evidence from observational studies Best action may differ depending on circumstances or patient's or societal values. Higher-quality research may well have an important impact on confidence in the estimate of effect and may change the estimate
Weak recommendation, low- or very-low-quality evidence, Grade 2C Uncertainty in the estimates of benefits, risks, and burden; benefits, risk, and burden may be closely balanced Evidence for at least one critical outcome from observational studies, case series, or RCTs, with serious flaws or indirect evidence Other alternatives may be equally reasonable. Higher-quality research is likely to have an important impact on confidence in the estimate of effect and may well change the estimate
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

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

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate use of complementary therapies and integrative medicine in lung cancer

Potential Harms
  • Serious adverse events from acupuncture have been reported in the literature but appear to be rare. Precautions, including follow-up and infectious precautions, should be taken to reduce the rates of serious events.
  • Serious adverse events associated with massage therapy are extremely rare, especially when performed by trained professionals. The reported adverse events included cerebrovascular accidents, displacement of a ureteral stent, embolization of a kidney, hematoma, leg ulcers, nerve damage, posterior interosseous syndrome, pseudoaneurysm, pulmonary embolism, ruptured uterus, strangulation of the neck, thyrotoxicosis, and various pain syndromes. Most adverse effects were associated with exotic types of manual massage or massage delivered by laymen, whereas massage therapists were rarely implicated.

Qualifying Statements

Qualifying Statements
  • American College of Chest Physicians (ACCP) 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 the CHEST Web site.
  • Although the ACCP is moving toward the production of evidence profiles for all guideline recommendations, there were many recommendations for which profiles were not developed, mostly because of resource constraints. When possible, methodologists created evidence profiles, and all panelists were educated on how to read and interpret them. The population, intervention, comparator, and outcome (PICO)-based systematic literature review process was followed for most recommendations, but there were some that could have benefited from meta-analyses.
  • One limitation of all guidelines today is that they are not able to adequately address complex patients with multiple morbidities. This is largely because these patients are generally excluded from clinical trials and are often not included in observational studies. Since guidelines are reliant on evidence published in the peer-reviewed literature, the scientific foundation impedes the process of providing good guidance for these patients and is a limitation in these guidelines. Therefore, the ACCP encourages funding agencies to ensure that topics with limited evidence are addressed in future research.

Implementation of the Guideline

Description of Implementation Strategy

Dissemination and Implementation

These guidelines are widely disseminated through the CHEST journal publication, National Guideline 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 America College of Chest Physicians (ACCP) guidelines.

As the expanding research into diagnostic techniques and treatment options continues to evolve, the guidelines must be updated and kept current. This edition of the ACCP Lung Cancer Guidelines will be the last to be published as a complete collection, as the ACCP is now embarking on a new living guidelines model (LGM) for revising existing recommendations and developing new recommendations as the literature evolves. This will include a continual assessment of the currency of these recommendations relevant to new research studies as they are published. The review cycle for the ACCP Lung Cancer Guidelines will begin 1 year after publication unless the content experts who monitor the literature bring a recommendation or set of related recommendations to the attention of the Guideline oversight Committee (GOC), suggesting that those recommendations are in need of updating sooner. The new LGM will permit a more nimble approach to guideline development but also requires a point-of-care accessible vehicle, CHEST Evidence, for the users to readily search for the most current version. These features will be described in greater detail in upcoming publications. As a step in this direction, these guidelines will be published primarily online with a printed version of the Executive Summary, containing all of the recommendations, the introduction, and this article on methodology. All narratives for each article with their supporting tables, figures, and algorithms will be available online at journal.publications.chestnet.org External Web Site Policy.

Implementation Tools
Mobile Device Resources
Patient Resources
Quick Reference Guides/Physician Guides
Resources
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)
Deng GE, Rausch SM, Jones LW, Gulati A, Kumar NB, Greenlee H, Pietanza MC, Cassileth BR. 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. Chest. 2013 May;143(5 Suppl):e420S-36S. [159 references] PubMed External Web Site Policy
Adaptation

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

Date Released
2007 Sep (revised 2013 May)
Guideline Developer(s)
American College of Chest Physicians - Medical Specialty Society
Source(s) of Funding
  • The development of this guideline was supported primarily by the American College of Chest Physicians (ACCP). 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.
  • Role of sponsors: The ACCP was solely responsible for the development of these guidelines. The remaining supporters played no role in the development process. External supporting organizations cannot recommend panelists or topics, nor are they allowed prepublication access to the manuscripts and recommendations. Further details on the Conflict of Interest (COI) Policy are available online at http://chestnet.org External Web Site Policy.
  • See the methodology companion (see the "Availability of Companion Documents" field) for a complete discussion of the source of funding for this guideline.
Guideline Committee

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

Composition of Group That Authored the Guideline

Authors: Gary E. Deng, MD, PhD; Sarah M. Rausch, PhD; Lee W. Jones, PhD; Amitabh Gulati, MD; Nagi B. Kumar, PhD, RD; Heather Greenlee, ND, PhD; M. Catherine Pietanza, MD; Barrie R. Cassileth, PhD, FCCP

Financial Disclosures/Conflicts of Interest
  • Conflicts of Interest (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.
  • Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
  • See the methodology companion (see the "Availability of Companion Documents" field) for a complete discussion of the conflict of interest procedures and requirements for the guideline panel.
Guideline Endorser(s)
American Association for Bronchology and Interventional Pulmonology - Medical Specialty Society
European Society of Thoracic Surgeons - Professional Association
Oncology Nursing Society - Professional Association
Society of Thoracic Surgeons - Medical Specialty Society
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Cassileth BR, Deng GE, Gomez JE, Johnstone PA, Kumar N, Vickers AJ, American College of Chest Physicians. Complementary therapies and integrative oncology in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007 Sep;132(3 Suppl):340S-54S.

Guideline Availability

Electronic copies: Available to subscribers of Chest - The Cardiopulmonary and Critical Care Journal External Web Site Policy. Also available to Chest subscribers through the Chest app External Web Site Policy for iPhone and iPad.

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

Availability of Companion Documents

The following are available:

  • 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. Supporting data. Electronic copies: Available to subscribers of Chest - The Cardiopulmonary and Critical Care Journal External Web Site Policy.
  • Detterbeck FC, Zelman Lewis S, Diekemper R, Addrizzo-Harris D, Alberts MW. Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Executive summary. Chest 2013 May;143(5 Suppl):7S-37S. Electronic copies: Available from the Chest - The Cardiopulmonary and Critical Care Journal Web site External Web Site Policy.
  • Alberts WM. 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 May;143(5 Suppl):38S-40S. Electronic copies: Available from the Chest - The Cardiopulmonary and Critical Care Journal Web site External Web Site Policy.
  • Zelman Lewis S, Diekemper R, Addrizzo-Harris DJ. 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. Chest 2013 May;143(5 Suppl):41S-e50S. Electronic copies: Available from the Chest - The Cardiopulmonary and Critical Care Journal Web site External Web Site Policy.
  • Alberg AJ, Brock MV, Ford JG, Samet JM, Spivack SD. Epidemiology of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2013 May;143(5 Suppl):e1S-e29S. Electronic copies: Available to subscribers of Chest - The Cardiopulmonary and Critical Care Journal External Web Site Policy.
  • Nana-Sinkham SP, Powell CA. Molecular biology of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2013 May;143(5 Suppl):e30S-e39S. Electronic copies: Available to subscribers of Chest - The Cardiopulmonary and Critical Care Journal External Web Site Policy.

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

The following is also available:

Patient Resources

The following is available:

  • Lung cancer: understanding the diagnosis. Northbrook (IL): American College of Chest Physicians; 2010. 7 p. Electronic copies: Available in Portable Document Format (PDF) from the OneBreath.org Web site External Web Site Policy.

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 November 30, 2007. The information was verified by the guideline developer on December 21, 2007. This NGC summary was updated by ECRI Institute on August 21, 2013.

Copyright Statement

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

Disclaimer

NGC Disclaimer

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

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