Lung cancer The diagnosis and treatment of lung cancer

Lung cancer
The diagnosis and treatment of lung cancer
Issued: April 2011
NICE clinical guideline 121
guidance.nice.org.uk/cg121
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guidelines. Accreditation is valid for 5 years from September 2009 and applies to guidelines produced
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2009). More information on accreditation can be viewed at www.nice.org.uk/accreditation
© NICE 2011

Contents
Introduction..................................................................................................................................4
Patient-centred care.....................................................................................................................6
Key priorities for implementation..................................................................................................7
1 Guidance...................................................................................................................................9
1.1 Access to services and referral.........................................................................................................9
1.2 Communication.................................................................................................................................11
1.3 Diagnosis and staging.......................................................................................................................12
1.4 Treatment.........................................................................................................................................17
1.5 Palliative interventions and supportive and palliative care................................................................25
1.6 Follow-up and patient perspectives...................................................................................................27
2 Notes on the scope of the guidance..........................................................................................29
3 Implementation.........................................................................................................................30
4 Research recommendations.....................................................................................................31
4.1 Selection of patients with NSCLC for treatment with curative intent.................................................31
4.2 Effectiveness of surgery with or without multimodality treatment in N2 disease...............................31
4.3 Pulmonary rehabilitation, optimisation of drug treatment and enhanced recovery programmes......32
4.4 New regimens for radiotherapy with curative intent..........................................................................32
4.5 Imaging modalities for monitoring response and recurrent disease..................................................32
5 Other versions of this guideline.................................................................................................34
5.1 Full guideline.....................................................................................................................................34
5.2 NICE pathway...................................................................................................................................34
5.3 Information for the public...................................................................................................................34
6 Related NICE guidance.............................................................................................................35
7 Updating the guideline...............................................................................................................37
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Appendix A: The Guideline Development Group, National Collaborating Centre and NICE
project team..................................................................................................................................38
2011 Guideline Development Group.......................................................................................................38
2005 Guideline Development Group.......................................................................................................39
National Collaborating Centre for Cancer...............................................................................................42
NICE project team...................................................................................................................................42
Appendix B: The Guideline Review Panel....................................................................................44
2011 Guideline Review Panel.................................................................................................................44
2005 Guideline Review Panel.................................................................................................................44
Appendix C: The algorithms.........................................................................................................45
About this guideline......................................................................................................................46
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Introduction
This guidance updates and replaces NICE clinical guideline 24 (published February 2005).
There are more than 39,000 new cases of lung cancer in the UK each year and more than
35,000 people die from the condition; more than for breast cancer and colorectal cancer
combined. Lung cancer is now the leading cause of cancer death in women.
About 90% of lung cancers are caused by smoking. Now that fewer men smoke, lung cancer
deaths in men have decreased by more than a quarter in the UK (a 27% reduction between 1971
and 2006). However, the number of women who smoke has risen and deaths from lung cancer in
women have increased.
Only about 5.5% of lung cancers are currently cured. Although the cure rate is rising slowly, the
rate of improvement has been slower than for other common cancers. Outcomes in the UK are
worse than those in some European countries and North America. There is evidence that
outcomes vary within the UK, which – among other factors – may be explained by variations in
the standard of care.
This updated guideline provides recommendations for good practice in the diagnosis and
treatment of non-small-cell (NSCLC) and small-cell lung cancer (SCLC).
The guideline will assume that prescribers will use a drug's summary of product characteristics to
inform decisions made with individual patients.
Changes in this update
New and updated recommendations are included on communication, diagnosis and staging,
selection of patients with non-small-cell lung cancer (NSCLC) for treatment with curative intent,
surgery with curative intent for NSCLC, smoking cessation, combination treatment for NSCLC,
treatment for small-cell lung cancer (SCLC), managing endobronchial obstruction, managing
brain metastases, and follow-up and patient perspectives.
Recommendations are marked as[2005],[2011]or[new 2011].
[2005]indicates that the evidence has not been updated and reviewed since 2005.
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[2011]indicates that the evidence has been reviewed but no changes have been made to
the recommendation.
[new 2011]indicates that the evidence has been reviewed and the recommendation has
been added or updated.
Since publication of NICE clinical guideline 24 in 2005, a number of new systemic therapies have
been granted a marketing authorisation by the European Medicines Agency for use in people
with NSCLC. NICE has published technology appraisals for pemetrexed, gefitinib and erlotinib.
Other technology appraisals are in development.
The NHS has also commissioned a review of first-line therapy for NSCLC through the NIHR
Health Technology Assessment Programme. This review is due to be published in 2011.
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Patient-centred care
This guideline offers best practice advice on the care of adults with lung cancer.
Treatment and care should take into account patients' needs and preferences. People with lung
cancer should have the opportunity to make informed decisions about their care and treatment,
in partnership with their healthcare professionals. If patients do not have the capacity to make
decisions, healthcare professionals should follow theDepartment of Health's advice on consent
and thecode of practice that accompanies the Mental Capacity Act. In Wales, healthcare
professionals should followadvice on consent from the Welsh Government.
Good communication between healthcare professionals and patients is essential. It should be
supported by evidence-based written information tailored to the patient's needs. Treatment and
care, and the information patients are given about it, should be culturally appropriate. It should
also be accessible to people with additional needs such as physical, sensory or learning
disabilities, and to people who do not speak or read English.
If the patient agrees, families and carers should have the opportunity to be involved in decisions
about treatment and care.
Families and carers should also be given the information and support they need.
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Key priorities for implementation
The following recommendations have been identified as priorities for implementation.
The importance of early diagnosis
The public needs to be better informed of the symptoms and signs that are characteristic of
lung cancer, through coordinated campaigning to raise awareness.[2005]
Communication
Ensure that a lung cancer clinical nurse specialist is available at all stages of care to support
patients and carers.[new 2011]
Diagnosis and staging
Choose investigations that give the most information about diagnosis and staging with the
least risk to the patient. Think carefully before performing a test that gives only diagnostic
pathology when information on staging is also needed to guide treatment.[new 2011]
Offer PET-CT, or EBUS-guided TBNA, or EUS-guided FNA, or non-ultrasound-guided TBNA
as the first test for patients with anintermediate probability of mediastinal malignancy
(lymph nodes between 10 and 20mm maximum short axis on CT) who are potentially
suitable for treatment with curative intent.[new 2011]
Surgery with curative intent for non-small-cell lung cancer
Offer patients with NSCLC who are medically fit and suitable for treatment with curative
intent, lobectomy (either open or thoracoscopic) as the treatment of first choice. For patients
with borderline fitness and smaller tumours (T1a–b, N0, M0), consider lung parenchymal-
sparing operations (segmentectomy or wedge resection) if a complete resection can be
achieved.[new 2011]
Radiotherapy with curative intent for non-small-cell lung cancer
Radical radiotherapy is indicated for patients with stage I, II or III NSCLC who have good
performance status (WHO 0, 1) and whose disease can be encompassed in a radiotherapy
treatment volume without undue risk of normal tissue damage
[1]
.[2005]
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Combination treatment for non-small-cell lung cancer
Ensure all patients potentially suitable for multimodality treatment (surgery, radiotherapy and
chemotherapy in any combination) are assessed by a thoracic oncologist and by a thoracic
surgeon.[new 2011]
Assessing patients with small-cell lung cancer
Arrange fo