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Toward Excellence in Testosterone Testing: A Consensus Statement

William Rosner, Hubert Vesper and on behalf of The Endocrine Society the endorsing organizations

J. Clin. Endocrinol. Metab. 2010 95: 4542-4548, doi: 10.1210/jc.2010-1314

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Copyright © The Endocrine Society. All rights reserved. Print ISSN: 0021-972X. Online
S P E C I A L F E A T U R E

C o n s e n s u s S t a t e m e n t

Toward Excellence in Testosterone Testing:


A Consensus Statement

William Rosner and Hubert Vesper, on behalf of The Endocrine Society and the
endorsing organizations*
St. Luke’s/Roosevelt Hospital Center and Columbia University College of Physicians and Surgeons (W.R.),
New York, New York 10019; and Centers for Disease Control and Prevention, Division of Laboratory
Services/Clinical Chemistry Branch (H.V.), Atlanta, Georgia 30341

Background: Testosterone assays are widely used. However, deficiencies in these assays limit their
broad and effective implementation and threaten the health of those patients whose medical care
relies upon its accurate measurement. Furthermore, the translation of research findings into in-
formation useful for patient care, such as new evidence-based clinical guidelines, is not possible
unless both research and clinical assays are held to higher standards than are currently required.
A group of concerned stakeholders was convened to address this problem.

Methods: Representatives of multiple professional societies, government, and industry, having a


stake in ensuring that testosterone levels are measured accurately and reliably, met to identify
goals, objectives, and actions necessary to bring about the standardization of assays for
testosterone.

Results: To ensure highly accurate testosterone testing that will result in improved diagnosis,
treatment, and prevention of disease through the use of standardized assays, a series of recom-
mendations were agreed upon. The recommendations included the following: technical improve-
ments for assay standardization; education of health care providers, patients, and all others con-
cerned with testosterone testing; plans to encourage all concerned journals, government agencies,
and health insurance companies to support this effort; and encouragement to manufacturers to
develop better and more cost effective assays.

Conclusion: A preliminary timeline was set out to implement the recommendations of the Group.
(J Clin Endocrinol Metab 95: 4542– 4548, 2010)

n February 18 and 19, 2010, The Endocrine Society, of a consensus on the issue of testosterone assay standard-
O in partnership with the Centers for Disease Control
and Prevention (CDC), convened a meeting of represen-
ization. Organizations interested in steroid hormone test-
ing in the United States were invited and were represented
tatives of multiple professional societies, government, and at the meeting. (For a list of meeting participants and or-
industry who have a stake in ensuring that testosterone ganizations represented, see Supplemental Appendix I,
levels are measured accurately and reliably. This objective published on The Endocrine Society’s Journals Online
is necessary to meet research, patient care, and public web site at http://jcem.endojournals.org.) The findings of
health needs. the group were summarized by the two authors and cir-
The spectrum of conference participants was designed culated to all participants for comments and suggestions.
to ensure that a broad range of perspectives informed the Revisions representing the consensus of the group were
identification of goals and objectives and the development incorporated into this statement.

ISSN Print 0021-972X ISSN Online 1945-7197


Printed in U.S.A.
Copyright © 2010 by The Endocrine Society
doi: 10.1210/jc.2010-1314 Received June 9, 2010. Accepted August 5, 2010.
* See Supplemental Appendix II for endorsing organizations.

4542 jcem.endojournals.org J Clin Endocrinol Metab, October 2010, 95(10):4542– 4548


J Clin Endocrinol Metab, October 2010, 95(10):4542– 4548 jcem.endojournals.org 4543

The final consensus statement was sent to interested or- • Manufacturers and laboratories should continue to
ganizations for consideration of endorsement, whether or work to develop new methodological approaches for
not they participated in the meeting. Some organizations that ensuring the sensitive, specific, accurate, and cost-ef-
participated in the conference chose not to endorse the state- fective measurement of testosterone.
ment for a variety of reasons. However, nonendorsement
does not imply, nor should it be interpreted to mean, that
these organizations disagree with all statements in the doc- Background
ument. The final manuscript was approved by all the endors-
The use of testosterone assays for both patient care and
ing organizations; hence, the consensus should be considered
research is increasing as new research links testosterone to
as summarizing the views of those organizations.
a variety of diseases and conditions and new treatment
The overarching goal of this collaborative effort is to im-
options become available. In addition, there is increased
prove the quality of research, patient care, and public health
interest in testosterone therapy for a number of clinical
through broad implementation of standardized testosterone
applications. Important discrepancies and inaccuracies in
measurements that are accurate, reliable, and comparable
measurements resulting from various testosterone assays
over time. This document presents all stakeholders with a call
are widespread, especially in the critical low ranges of
to action to actively participate in this effort.
testosterone concentration, e.g. those observed in women,
In brief, the following recommendations represent the
children, and hypogonadal males. The Endocrine Society
consensus of the assembled group of stakeholders (see
published a statement summarizing the evidence of these
Recommendations for a more detailed explanation of the
deficiencies and recommending accuracy-based testing of
recommendations, and see Supplemental Appendix II for
testosterone and calibration of all methods traceable to a
a list of organizations that have endorsed this report).
single high-level reference material (1).
• All stakeholders [physicians, other health care providers, Testosterone assays are widely used in clinical research,
laboratories, diagnostic manufacturers, health care orga- epidemiological studies, and patient care. However, defi-
nizations, professional societies, pharmaceutical compa- ciencies in these assays limit their broad and effective im-
nies, insurance companies, the National Institutes of plementation and threaten the health of those patients
Health (NIH) and other government agencies] should ac- whose medical care relies upon accurate measurement of
knowledge the importance of testosterone assay standard- testosterone. Furthermore, the translation of research
ization and of the current standardization effort and findings into information useful for patient care, such as
should work closely with the CDC to formulate plans new evidence-based clinical guidelines, is not possible un-
to implement accuracy-based, calibrated testing less both research and clinical assays are held to higher
across the entire community of providers and users of standards than are currently required.
these assays. It should also be noted that inaccurate testing has signif-
• The expert scientific and medical communities (indi- icant cost implications in addition to potential negative im-
viduals with scientific and medical expertise in the mea- pact on patient health. Frequent retesting may be required,
surement of testosterone and its clinical application) and patients may be subject to expensive treatments that are
should work to define performance criteria that cover inappropriate to their actual condition, unnecessarily expos-
the full range of expected values, from children to adult ing them to the risk of adverse effects of therapy. High-qual-
males and females. ity testosterone testing can contribute to helping rein in costs
• The expert scientific and medical communities should while providing better outcomes in patient care.
work together to define reference intervals for testoster- The problems relate to the measurement process, and
one in adults and children of both sexes. not to the utility of testosterone as a biomarker. Specific
• The expert scientific and medical communities should issues are lack of measurement accuracy, specificity, sen-
develop guidelines and protocols to ensure uniform pa- sitivity, and precision/repeatability, especially at low tes-
tient preparation and handling of samples before they tosterone concentrations. To address these challenges, the
are assayed. clinical and research communities have called for the stan-
• Third-party payers and health care organizations dardization of testosterone testing.
should promote the use of assays that have been stan- Although methods for measuring testosterone in blood
dardized through the above-mentioned efforts and serum or plasma have improved, there is no accuracy-
should work with relevant organizations and agencies based standard to which these assays are held. Conse-
to enable payment only for such standardized assays. quently, many widely used tests do not provide accurate
• Funding entities, journals, and others involved in re- results across the range of testosterone concentrations ap-
search should support the standardization of assays. plicable to patient care. Furthermore, currently recog-
4544 Rosner and Vesper Consensus Statement on Testosterone Testing J Clin Endocrinol Metab, October 2010, 95(10):4542– 4548

nized reference intervals for testosterone vary widely de- hicles present tremendous potential for providing critical
pending on the specific assay and population used to educational content to physicians and other health care
establish the intervals, further complicating the interpre- providers. Of particular importance are both society-
tation of results. sponsored and independent journals and their peer review
In 2007, the Clinical Chemistry Branch (CCB), Divi- systems. By accepting only research studies that use stan-
sion of Laboratory Sciences (DLS), National Center for dardized tests, journals could have a significant impact in
Environmental Health, CDC, responded to this need by advancing the transition to accuracy-based assays. Clini-
starting a project to standardize testosterone testing. As cal researchers should budget for the cost of standardized
part of this effort, the CDC has worked with researchers tests to ensure that their research results are acceptable for
to develop and implement the technical components publication, and funding agencies should recognize the
needed for standardization of testosterone assays. It has necessity of these budget items (see the paragraph regard-
partnered with The Endocrine Society and other con- ing funding entities, journals, and others involved in re-
cerned organizations to help disseminate information on search in Recommendations).
testosterone testing and provide interpretation to the clin-
ical and research community. Clinical laboratory directors and their associations
Improving the state of testosterone assays will require Like practitioners, clinical laboratory directors must
the active participation of all stakeholder groups, and the understand the benefits of accurately calibrated testing.
purpose of this consensus statement is to issue a call to Laboratories will need to be aware of the available re-
action to the broader medical and research communities, sources and how to access them. They will also need to
third-party payers, assay manufacturers, pharmaceutical understand any applicable procedures for standardization
companies, laboratories, regulatory agencies, research and certification. Although some laboratory directors
funding agencies, professional organizations, and scien- may have limited funds with which to implement an ac-
tific and medical journals. Each group stands to benefit curacy-based program, they must consider the return on
from improved testosterone assays, and each bears a re- investment to be gained by providing an enhanced service.
sponsibility for improving the accuracy of these assays to
benefit patients and improve public health. Regulatory agencies
Agencies such as the U.S. Food and Drug Administra-
tion (FDA), state regulatory agencies, laboratory accred-
Principal Stakeholders in Improving the itation agencies, and similar organizations will need to be
Quality of Testosterone Testing appropriately engaged to ensure the use of standardized
tests. For example, FDA endorsement of standardized
Accurate, reliable, and appropriately sensitive testoster-
tests—such as those achieved with the CDC standardiza-
one testing is of great importance to a wide variety of
tion program, CDC Standardization Process: CDC Ac-
stakeholders, each of which will benefit from better assays
tivities—and insistence on accuracy-based evaluation for
and bears some responsibility in improving the situation.
new diagnostics would have a tremendous impact. Other
organizations would likely follow suit, thereby establish-
Physicians and other health care providers
ing broad expectations for accuracy-based standards of
Physicians and other health care providers, including
testosterone assays.
endocrinologists—reproductive and pediatric endocrinol-
ogists, among others—pediatricians, urologists, gerontol-
ogists and geriatricians, primary care practitioners, obste- Diagnostic manufacturers and their associations
tricians and gynecologists, and osteoporosis specialists The diagnostic-device community must understand
must understand the importance of using accurately cal- both the costs and benefits of the new system and be en-
ibrated testosterone tests. To ensure this understanding, couraged to participate in the CDC effort. Although they
health care providers must be informed about the poten- may initially incur new costs, manufacturers who are early
tial ramifications of using tests that aren’t standardized supporters are likely to see benefits in the forms of im-
and must be educated on the application and interpreta- proved products, enhanced reputation, positive word-of-
tion of appropriately calibrated tests. mouth publicity, and an avoidance of the potential prob-
lems associated with inadequate tests.
Medical societies and medical journals
Medical societies are central to education and the dis- Pharmaceutical companies
semination of information. Their annual meetings, other Pharmaceutical companies have an incentive for im-
educational programs, and member communication ve- proved testosterone measurements. Without appropriate
J Clin Endocrinol Metab, October 2010, 95(10):4542– 4548 jcem.endojournals.org 4545

assays, clinical trials will fail to identify legitimate differ- Standardization Process: CDC Activities
ences in testosterone levels between control and test
groups and will not be accurate or reproducible. Without The CDC has the means in place to address the problems
sound, reproducible evidence of a need for new therapeu- of testosterone testing. As part of this project, DLS/CCB
tic applications for testosterone, the FDA will be unable to performed the following activities:
approve new uses for this important hormone. Further- • Started a laboratory standardization project in 2010 in
more, excellence in testing would allow the accurate di- which assay manufacturers and laboratories that use
agnosis, treatment, and monitoring of those who have an self-developed, in-house methods can enroll. The
indication for currently approved testosterone therapies. project offers assistance in improving assay accuracy
and monitors accuracy over time.
Third-party payers (group insurance carriers, • Established a laboratory to perform reference measure-
Medicare) and health care organizations ments for characterizing matrix-based materials, as-
Accurate testing may cost more initially. However, in sessing accuracy, precision, sensitivity, and specificity
the long run, such accuracy will save money for third-party of assays.
payers, eliminating the need for repeated testing and lead- • Assessed new reference material developed by the Na-
ing to better, more efficient treatment and patient care. tional Institute for Standards and Technology (NIST)
for its suitability as calibrators for immunoassays (com-
Further broad-based standardization will eliminate the
mutability study).
need for laboratories to create their own reference inter-
• Conducted an interlaboratory comparison to assess the
vals, thereby reducing costs. Efforts should be made to
measurement variability among laboratories using
enlist the support of the Centers for Medicare and Med-
mass spectrometry. Results have been published in the
icaid Services (CMS), which establishes policy for Medi-
peer-reviewed literature (2).
care reimbursement. Support of the CMS for standardized
• Collaborated with the College of American Patholo-
testing would ultimately have a positive impact on all
gists on a new calibration/calibration verification ser-
payers.
vice that is available in 2010.
• Sponsored a workshop with researchers and assay manu-
NIH and other funding agencies facturers to collect further information about the problem of
NIH and other funding entities should require the use steroid measurements and to discuss solutions to these prob-
of standardized testing when awarding grants for studies lems. Results of the studies and the workshop are available in
that measure testosterone levels. The agencies need to ac- a special issue of the journal Steroids (3).
knowledge and provide for any additional costs that are • Collaborated with Boston University on establishing
required for high-quality measurements, recognizing that reference intervals using a subpopulation of the Fra-
these costs are both important and small in the scheme of mingham Heart Study.
most research applications. • Presented workshops and symposia at the annual meet-
ing of the American Association of Clinical Chemistry
and The Endocrine Society in 2007 and 2008.
Patients and patient support groups
• Established collaborations with The Endocrine Society,
Patients will be the ultimate beneficiaries of high-qual-
American Association of Clinical Chemists (AACC),
ity testing, and their support of standardization is critical.
American Association of Clinical Endocrinologists
Patient support organizations will need to develop edu-
(AACE), the College of American Pathologists, and
cation and outreach efforts to help patients understand the
NIST on improving steroid hormone measurements.
importance of accuracy-based standards, providing an ap-
• Planned workshops and symposia at the 2010 annual
preciation for the benefits of standardized testing. In-
meetings of the AACC, AACE, and The Endocrine
formed patients can engage in proactive discussions with
Society.
their physicians about the reliability and implications of
their testosterone tests. The reference methods developed at the CDC will allow
These stakeholders are all part of an integrated system, others to calibrate their methods. Furthermore, the CDC
and all must be engaged in the effort if the overall goal of will offer its reference measurement services to assay man-
standardization leading to quality research and care is to ufacturers and providers of proficiency testing programs
be achieved. In addition, although this effort is originating to characterize materials and monitor performance. It is
in the United States, global standards will be essential for planned to have DLS/CCB reference methods recognized
success; this should be a broad effort that involves relevant internationally through appropriate accreditation bodies
international communities. such as the Joint Committee for Traceability in Laboratory
4546 Rosner and Vesper Consensus Statement on Testosterone Testing J Clin Endocrinol Metab, October 2010, 95(10):4542– 4548

Medicine (JCTLM). Furthermore, DLS/CCB is working the context of valid reference intervals. Gaining agree-
with other established, JCTLM-listed reference laboratories ment on criteria that should be used when defining ref-
and metrological institutions to assure comparability of its erence intervals is an important step in this process.
results on an international level and traceability to the highest • The expert scientific and medical communities should de-
metrological standard. This CDC standardization program velop guidelines and protocols to ensure uniform patient
uses the same approaches as those proven effective in im- preparation and handling of samples before they are as-
proving patient care and public health such as the CDC sayed. It is not sufficient to provide technical excellence in
standardization program for cholesterol and blood lipids assay methodologies. It is also necessary to define and
and the National Glycohemoglobin Standardization Pro- control preanalytical variables in both patient preparation
gram for A1c. and specimen collection. Once guidelines describing ap-
propriate patient and sample preparation are defined, it
will also be necessary to develop a system for monitoring
Recommendations and oversight to ensure quality test results.
• Third-party payers and health care organizations
The purpose of this effort is to ensure highly accurate tes- should promote the use of assays that have been stan-
tosterone testing that will result in improved diagnosis, dardized through the above-mentioned efforts and
treatment, and prevention of disease through the use of should work with relevant organizations and agencies
standardized assays. The following recommendations are to enable payment only for such standardized assays.
essential to achieving this goal. Medicare, insurance companies, other third-party pay-
• All stakeholders should acknowledge the importance of ers, and health care organizations could present a major
testosterone assay standardization and of the current impetus for change by recognizing the value of accurate
standardization effort and should work closely with the testing. By reimbursing providers only for standard-
CDC to formulate plans to implement accuracy-based, ized, accuracy-based tests, payers would encourage
calibrated testing across the entire community of pro- providers to order the appropriate tests the first time,
viders and users of these assays. The CDC has taken the thereby promoting efficiency by avoiding inaccurate,
lead in responding to the widespread concerns about unreliable test results and unnecessary repeat testing.
the quality of testosterone testing. The informed clinical Furthermore, in cases requiring repeat testing, such as
and scientific communities support these efforts and in the diagnosis of hypogonadism in men, accurate tests
will work together to ensure that the appropriate assays would aid in both diagnosis and the development of a
are developed, recognized, and made widely available treatment plan.
to promote their utilization. It is important that the • Funding entities, journals, and others involved in re-
broader scientific and medical communities demand ac- search should support the standardization of assays.
curacy-based standards for testosterone assays, that Accurate testing may incur additional up-front costs,
manufacturers and laboratories provide accurate and and it is essential that these costs be supported. NIH and
reliable tests, and that research funding agencies and other funding entities should be prepared to cover these
third-party payers reimburse accordingly. costs in grants. Journals should accept only research
• The expert scientific and medical communities should results that are based on high-quality, standardized
work to define performance criteria that cover the full tests, the results of which are based on demonstrable
range of expected values, from children to adult males accuracy. When selecting tests for patient care and re-
and females. The CDC has developed initial criteria, search, or when supporting research and public health
which will need to be expanded and refined. Although activities, an assessment of whether tests are standard-
the broad principles of accuracy and precision require- ized to CDC should become part of the selection and
ments for testosterone assays are in place, the details of support granting process. Successful standardization to
the application of these principles are currently in flux. the CDC should also become part of the evaluation
Those details will be continually assessed by experts process for new testosterone tests.
in the field as this project evolves. • Manufacturers and laboratories should continue to
• The expert scientific and medical communities should work to develop new methodological approaches for
work together to define reference intervals for testos- ensuring the sensitive, specific, accurate, and cost-ef-
terone in adults and children of both sexes. Reference fective measurement of testosterone. The emphasis of
intervals established through calibrated methods are the CDC effort is on gaining agreement on measure-
required for the useful interpretation of results. Im- ment results, rather than focusing on specific method-
proved measurements will have their full impact only in ologies. Assay and instrument manufacturers should be
J Clin Endocrinol Metab, October 2010, 95(10):4542– 4548 jcem.endojournals.org 4547

encouraged to develop new assays and methodologies Appendix I


that perform at a level that meets all the clinical and
public health needs. In the end, high-quality testoster- Toward Excellence in Testosterone Testing
one testing should produce comparable test results A Consensus Conference
(within an accepted variance) across methods and time. February 18 –19, 2010, Atlanta, GA

Preliminary Timeline Attendees


William Rosner, The Endocrine Society (Conference
Several years will be required to reach the desired quality
Chair)
and consistency in testosterone testing. Manufacturers,
Hubert Vesper, Centers for Disease Control and Pre-
physicians, third-party payers, and patients all need to
vention (CDC)
prepare for these changes. The proposed changes will be
introduced over time, giving the principal stakeholders Ricardo Azziz, Androgen Excess and PCOS Society
time to adapt their policies and practices. A timeline and (AEPCOS)
resource plan for the described activities will be developed Patricia Beaston, Food and Drug Administration (FDA)
by The Endocrine Society together with collaborating part- Sarah Berga, Androgen Excess and PCOS Society (AEP-
ners, with realistic milestones. The CDC criteria are based on COS)/American College of Obstetricians and
what is feasible today, and the criteria may be tightened over Gynecologists (ACOG)
time as new information becomes available. John Brennan, Solvay Pharmaceuticals
In parallel to the scientific work to advance this process Enrico Carmina, Androgen Excess and PCOS Society
is a broad communication and engagement strategy. A (AEPCOS)
Working Group is being established to provide ongoing Kevin Cavanagh, Association of Public Health Laborato-
advice and coordination and to monitor progress and ries (APHL)
identify any specific next steps. The Endocrine Society Walt Chandler, Laboratory Corporation of America
staff is taking the coordinating lead, involving staff from (LabCorp)
other participating societies and recommending a pro- Nigel Clarke, Nichols Institute—Quest Diagnostics
posed multisociety structure for moving forward. Loretta Doan, The Endocrine Society
Preliminary milestones include: John Eckfeldt, College of American Pathologists (CAP)
Esther Eisenberg, Eunice Kennedy Shriver National Institute
2010
of Child Health and Human Development (NICHD)
Consensus document is published.
Robert Fitzgerald, American Association for Clinical
Working group is formed and develops multisociety
Chemistry (AACC)
structure.
Task forces are created to address specific items Luigi Garibaldi, Lawson Wilkins Pediatric Endocrine So-
stated in the recommendations (i.e. task force on refer- ciety (LWPES)
ence intervals, on performance criteria, on preanalytical Scott Hunt, The Endocrine Society
issues, etc.). Alexander Katayev, Laboratory Corporation of America
(LabCorp)
2011 Janet Kreizman, The Endocrine Society
Broad participation by laboratories and assay manu- Andrew La Barbera, American Society for Reproductive
facturers is achieved. Medicine (ASRM)
Performance criteria are refined. Alvin Matsumoto, American Society for Bone and Min-
eral Research (ASBMR)
2012
Gary Myers, Centers for Disease Control and Prevention
Sufficient laboratories and assays are standardized to
(CDC)
CDC. Stakeholders are able to request standardized tests
Jon Nakamoto, Nichols Institute—Quest Diagnostics/
and to implement new policies and practices.
Lawson Wilkins Pediatric Endocrine Society (LWPES)
New, generally applicable reference intervals are
Darius Paduch, American Urological Association (AUA)
available.
Hershel Raff, The Endocrine Society
Ongoing Alan Rogol, Lawson Wilkins Pediatric Endocrine Soci-
Performance criteria are to be reviewed every 2 to 4 yr ety (LWPES)
and revised as needed. Samuel Testino, Solvay Pharmaceuticals
4548 Rosner and Vesper Consensus Statement on Testosterone Testing J Clin Endocrinol Metab, October 2010, 95(10):4542– 4548

Consultants Address all correspondence and requests for reprints to: Dr.
Jane Fisher, Cambridge Concord Associates William Rosner, St. Luke’s/Roosevelt Hospital Center, Depart-
ment of Medicine, 1000 10th Avenue, Endocrinology AJA 403,
Elaine Kuttner, Cambridge Concord Associates
New York, New York 10019. E-mail: wr7@columbia.edu.
Solvay Pharmaceuticals provided funding for this project
through the CDC Foundation. The Division of Laboratory Sci-
Appendix II ences at the National Center for Environmental Health and the
Division of Cancer Prevention and Control at the National Cen-
Endorsing Organizations ter for Chronic Disease Prevention and Health Promotion also
American Association for Clinical Chemistry contributed financially to this project.
There is a fee for participation in the CDC standardization
American Association of Clinical Endocrinologists
program; for more information, contact Hubert Vesper at
Androgen Excess/PCOS Society hav2@cdc.gov.
American Society for Bone and Mineral Research Disclosure Summary: The authors have nothing to disclose.
American Society for Reproductive Medicine
American Urological Association
Association of Public Health Laboratories
The Endocrine Society References
Laboratory Corporation of America 1. Rosner W, Auchus RJ, Azziz R, Sluss PM, Raff H 2007 Position
North American Menopause Society statement: utility, limitations, and pitfalls in measuring testosterone:
Pediatric Endocrine Society (formerly known as Lawson an Endocrine Society position statement. J Clin Endocrinol Metab
92:405– 413
Wilkins Pediatric Endocrine Society) 2. Vesper HW, Bhasin S, Wang C, Tai SS, Dodge LA, Singh RJ, Nelson
J, Ohorodnik S, Clarke NJ, Salameh WA, Parker Jr CR, Razdan R,
Monsell EA, Myers GL 2009 Interlaboratory comparison study of
serum total testosterone [corrected] measurements performed by
Acknowledgments mass spectrometry methods. Steroids [Erratum (2009) 74:791] 74:
498 –503
The authors acknowledge the contributions to the substance 3. Rosner W, Vesper H 2008 CDC workshop report on improving ste-
and/or editing of this document by the individuals listed in Sup- roid hormone measurements in patient care and research translation.
plemental Appendix I. Steroids 73:1285–1352

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