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Appropriateness Criteria

Variant 1: Adult. Newly diagnosed DCIS. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis diagnostic Usually appropriate Strong ☢☢ 0.1-1mSv 9 9 0 0 0 0 1 0 0 1 12
References Study Quality
48 (17693177) 2
47 (33242249) 1
46 (25599513) 2
45 (23963140) Good
44 (30466027) 3
43 (27411945) 3
42 (14684521) 4
41 (8191988) 3
40 (15797293) 4
39 (23370209) 3
38 (8109501) 4
37 (2549563) 4
36 (23826951) 3
35 (2536185) 4
3 (23774990) 3
Mammography diagnostic Usually appropriate Strong ☢☢ 0.1-1mSv 9 9 0 0 0 0 1 0 0 2 11
References Study Quality
52 (15486214) 3
48 (17693177) 2
47 (33242249) 1
45 (23963140) Good
44 (30466027) 3
43 (27411945) 3
42 (14684521) 4
41 (8191988) 3
40 (15797293) 4
39 (23370209) 3
38 (8109501) 4
37 (2549563) 4
36 (23826951) 3
35 (2536185) 4
3 (23774990) 3
46 (25599513) 2
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 4 7 2 1 0 0
References Study Quality
84 (33589308) 2
83 (26962097) 1
82 (19575283) 4
81 (34794600) 4
79 (28242086) 4
78 (-3196796) 4
77 (23949917) 3
61 (9015067) 4
52 (15486214) 3
35 (2536185) 4
80 (-3196797) 4
MRI breast without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 1 0 0 1 4 3 2 2 1
References Study Quality
73 (20217259) 3
72 (19375068) 4
71 (25919321) Good
70 (17443388) 3
69 (22517955) 3
68 (12734086) 3
67 (34342501) 1
66 (20956821) 4
65 (19864520) 4
64 (9377507) 4
63 (18024450) 3
62 (17983393) 3
61 (9015067) 4
60 (24108552) 4
59 (29139591) 3
58 (28750354) 2
48 (17693177) 2
Mammography with IV contrast Usually not appropriate Strong ☢☢ 0.1-1mSv 2 2 6 4 2 1 1 0 0 0 0
References Study Quality
58 (28750354) 2
57 (27345656) 2
56 (30678480) 2
55 (27611215) 3
54 (-3196794) 3
53 (34503181) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
34 (-3196793) 4
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
34 (-3196793) 4
CT chest without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
34 (-3196793) 4
FDG-PET breast dedicated Usually not appropriate Strong ☢☢☢ 1-10 mSv 1 1 11 1 2 0 0 0 0 0 0
References Study Quality
51 (31375867) 2
50 (28870933) 4
49 (11032590) 2
34 (-3196793) 4
Sestamibi MBI Usually not appropriate Moderate ☢☢☢ 1-10 mSv 1 1 8 1 3 1 1 0 0 0 0
References Study Quality
76 (31166752) 3
75 (22911882) 4
74 (23151912) Good
Variant 2: Adult. Newly diagnosed DCIS. No surgical intervention. Active surveillance.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis diagnostic Usually appropriate Moderate ☢☢ 0.1-1mSv 9 9 0 0 0 0 1 0 4 2 7
References Study Quality
86 (28705686) 4
87 (-3196799) 2
Mammography diagnostic Usually appropriate Moderate ☢☢ 0.1-1mSv 8 8 0 0 1 0 0 0 6 0 7
References Study Quality
88 (32125937) 3
87 (-3196799) 2
86 (28705686) 4
MRI breast without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 2 6 1 2 3 0
References Study Quality
88 (32125937) 3
87 (-3196799) 2
71 (25919321) Good
70 (17443388) 3
68 (12734086) 3
67 (34342501) 1
58 (28750354) 2
US breast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 1 1 0 0 0 0 0
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 2 2 7 4 3 0 0 0 0 0 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 1 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 1 0 0 0 0 0 0
Variant 3: Adult. Evaluation for local recurrence in patient with history of breast conservation therapy for DCIS. Routine surveillance.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 3 0 0 4 7
References Study Quality
108 (29064749) 4
107 (-3196801) 4
106 (20956827) 4
105 (29748762) 3
104 (25904721) 3
103 (24106867) 3
102 (24113745) 3
101 (28675577) 4
100 (23129741) 4
99 (36436961) 4
90 (9016233) 4
89 (17579163) 3
27 (-3196789) 4
Digital breast tomosynthesis screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 1 0 0 0 0 0 1 1 11
References Study Quality
111 (32529566) 3
110 (27163158) 3
109 (31313678) 3
108 (29064749) 4
107 (-3196801) 4
106 (20956827) 4
105 (29748762) 3
104 (25904721) 3
103 (24106867) 3
102 (24113745) 3
101 (28675577) 4
100 (23129741) 4
99 (36436961) 4
90 (9016233) 4
89 (17579163) 3
27 (-3196789) 4
Mammography diagnostic Usually appropriate Strong ☢☢ 0.1-1mSv 8 8 0 0 1 0 2 0 0 5 6
References Study Quality
113 (22692036) 3
112 (8511295) 2
111 (32529566) 3
110 (27163158) 3
109 (31313678) 3
108 (29064749) 4
107 (-3196801) 4
106 (20956827) 4
105 (29748762) 3
104 (25904721) 3
103 (24106867) 3
102 (24113745) 3
101 (28675577) 4
100 (23129741) 4
99 (36436961) 4
90 (9016233) 4
89 (17579163) 3
27 (-3196789) 4
Mammography screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 1 0 0 0 0 0 1 2 10
References Study Quality
113 (22692036) 3
111 (32529566) 3
110 (27163158) 3
109 (31313678) 3
108 (29064749) 4
107 (-3196801) 4
106 (20956827) 4
105 (29748762) 3
104 (25904721) 3
103 (24106867) 3
102 (24113745) 3
101 (28675577) 4
100 (23129741) 4
99 (36436961) 4
90 (9016233) 4
89 (17579163) 3
27 (-3196789) 4
MRI breast without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 0 4 6 0 2 2 0
References Study Quality
114 (-3196807) 4
US breast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 5 1 0 1 0 0 0 0
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 2 2 3 6 4 0 1 0 0 0 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 0 0 1 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 0 1 0 2 0 0 0 0
Variant 4: Adult. Evaluation for ipsilateral local recurrence in a patient with history of mastectomy for DCIS. Routine surveillance.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 2 0 1 0 0 0 0 0
References Study Quality
124 (23131395) 3
Digital breast tomosynthesis screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 2 0 0 0 0 0 0 0
Mammography screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 2 0 0 0 0 0 0 0
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 0 0 0 1 0 0 0 1
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 3 0 1 0 0 0 0 0
References Study Quality
123 (32374666) 4
114 (-3196807) 4
122 (-3196805) 4
121 (-3196803) 4
100 (23129741) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
122 (-3196805) 4
121 (-3196803) 4
100 (23129741) 4
CT chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
122 (-3196805) 4
121 (-3196803) 4
100 (23129741) 4
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
122 (-3196805) 4
121 (-3196803) 4
100 (23129741) 4
CT chest without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
122 (-3196805) 4
121 (-3196803) 4
100 (23129741) 4
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 1 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 0 0 1 0 0 0 0
Variant 5: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of breast conservation therapy for DCIS. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 3 4 6
References Study Quality
128 (21833567) 4
Digital breast tomosynthesis diagnostic Usually appropriate Strong ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 1 1 12
References Study Quality
126 (30392596) 4
125 (28473077) 4
45 (23963140) Good
44 (30466027) 3
43 (27411945) 3
42 (14684521) 4
36 (23826951) 3
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 0 3 11
References Study Quality
128 (21833567) 4
126 (30392596) 4
125 (28473077) 4
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 3 3 3 2 3 1 4 0 1 0 0
Image-guided core biopsy breast Usually not appropriate Limited Varies Varies 1 1 13 1 0 0 0 0 0 0 0
References Study Quality
127 (22039282) 4
Image-guided fine needle aspiration breast Usually not appropriate Limited Varies Varies 1 1 10 1 1 0 1 0 0 0 1
References Study Quality
127 (22039282) 4
MRI breast without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 7 4 3 0 0 0 0 0 0
References Study Quality
131 (32108973) 4
130 (23046046) 3
129 (28754486) 3
59 (29139591) 3
58 (28750354) 2
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 0 1 0 1 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 0 1 0 0 1 0 0 0
Variant 6: Adult. Suspected local recurrence based on symptoms, physical examination, or laboratory value in patient with history of mastectomy for DCIS. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 4 3 7
References Study Quality
126 (30392596) 4
125 (28473077) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 10 2 2 0 0 0 0 0 0
Mammography diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 10 2 1 1 0 0 0 0 0
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 10 2 1 0 1 0 0 0 0
Image-guided biopsy chest Usually not appropriate Moderate Varies Varies 1 1 13 0 1 0 0 0 0 0 0
References Study Quality
133 (22088803) 3
132 (27866091) Good
Image-guided fine needle aspiration chest Usually not appropriate Moderate Varies Varies 1 1 10 0 1 0 1 1 0 0 1
References Study Quality
133 (22088803) 3
132 (27866091) Good
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 1 4 0 0 1 1 0 0
References Study Quality
131 (32108973) 4
130 (23046046) 3
129 (28754486) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 0 0 1 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 0 0 1 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 0 0 0 0 0 0 1
Variant 7: Adult. Known DCIS with microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 4 2 0 0 0 0 0 0
US-guided core biopsy axillary node Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 3 0 1 0 0 0 0 1
US-guided fine needle aspiration biopsy axillary node Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 0 1 0 0 0 0 1
Digital breast tomosynthesis diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 14 0 0 0 0 0 0 0 0
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 13 1 0 0 0 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 1 1 0 0 1 0 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
Lymphoscintigraphy axilla Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 10 1 1 0 1 1 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
Variant 8: Adult. Known DCIS without microinvasion found on prior mammography, ultrasound, or MRI during initial evaluation. Axillary evaluation needed. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 2 1 0 0 0 0 1
US-guided core biopsy axillary node Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 0 0 0 0 0 0 1
US-guided fine needle aspiration biopsy axillary node Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 0 0 0 0 0 0 1
Digital breast tomosynthesis diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 13 1 0 0 0 0 0 0 0
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 14 0 0 0 0 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 0 0 0 0 0
References Study Quality
139 (34470633) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
Lymphoscintigraphy axilla Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 0 1 0 2 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.