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Prevention, Diagnosis, Therapy, and Follow-Up of Lung Cancer Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society*

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Prevention, Diagnosis, Therapy, and Follow-Up of Lung Cancer Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society* Guideline 39 Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society* Bibliography with the cooperation of the DOI http://dx.doi.org/ " German Society of Occupa- " German Society of Nuclear " German Radiologic Society, 10.1055/s-0030-1255961 " Online-Publikation: 14. 12. 2010 tional and Environmental Medicine, Austrian Society for " Pneumologie 2011; 65: Medicine, German Society for Palliative Haematology and Oncology, 39–59 © Georg Thieme " German Society for Care, " Austrian Society of Verlag KG Stuttgart · New York Epidemiology, " German Society of Pneumology, ISSN 0934-8387 " German Society of Haema- Pathology, " Austrian Society for Corresponding author tology and Oncology, " German Society of Radiation Radiation Oncology, Prof. Dr. med. Gerd Goeckenjan " German Society for Medical Oncology, Radiobiology and Medical Guideline coordinator Informatics, Biometrics and " German Society for Thoracic Radiophysics Am Ziegenberg 95 Epidemiology, Surgery, 34128 Kassel [email protected] Authors G. Goeckenjan1, H. Sitter2, H. Dienemann31, J. Müller-Nordhorn58, M. Thomas3, D. Branscheid4, W. Eberhardt32, S. Eggeling33, D. Nowak59, U. Ochmann59, M. Flentje5, F. Griesinger6, T. Fink34, B. Fischer35, B. Passlick60, I. Petersen61, N. Niederle7, M. Stuschke8, M. Franke36, G. Friedel37, R. Pirker62, B. Pokrajac63, T. Blum9, K.-M. Deppermann10, T. Gauler38, S. Gütz39, M. Reck64, S. Riha65, C. Rübe66, J. H. Ficker11, L. Freitag12, H. Hautmann40, A. Hellmann41, A. Schmittel67, N. Schönfeld68, A. S. Lübbe13, T. Reinhold14, D. Hellwig42, F. Herth43, W. Schütte69, M. Serke70, E. Späth-Schwalbe15, C. P. Heußel44, W. Hilbe45, G. Stamatis71, D. Ukena16, M. Wickert17, F. Hoffmeyer46, M. Horneber47, M. Steingräber72, M. Steins73, M. Wolf18, S. Andreas19, R. M. Huber48, J. Hübner49, E. Stoelben74, L. Swoboda75, T. Auberger20, R. P. Baum21, H.-U. Kauczor50, H. Teschler76, H. W.Tessen77, B. Baysal22, J. Beuth23, K. Kirchbacher51, D. Kirsten52, M. Weber78, A. Werner79, H. Bickeböller24, A. Böcking25, T. Kraus53, S. M. Lang54, H.-E. Wichmann80, R. M. Bohle26, I. Brüske27, U. Martens55, E. Irlinger Wimmer81, C. Witt82, O. Burghuber28, A. Mohn-Staudner56, H. Worth83 N. Dickgreber29, S. Diederich30, K.-M. Müller57, Institutions Institutions are listed at the end of article. * Abridged Version. Goeckenjan G et al. Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer… Pneumologie 2011; 65: 39 –59 40 Guideline 1 Methodological Introduction 2 Epidemiological Aspects of Lung Cancer ! ! This abridged version is based on an interdisciplinary guideline In all patients with lung cancer potential risk factors are to be in- which corresponds to development stage 3 (S3) of guidelines vestigated (smoking, occupational risk factors). A detailed history according to the classification of the Association of the Scientific of potential occupational exposures is mandatory (D). Medical Societies in Germany (AWMF). The guideline develop- ment process is characterized by the combination of formal evidence-search, formal consensus, logic (algorithms), decision 3 Prevention of Lung Cancer and outcome analysis, and interdisciplinary development with ! the cooperation of 15 German and Austrian medical societies. Any exposure to tobacco smoke and secondhand smoking should ●" Table 1 shows the relationship between levels of evidence, be avoided (A). consensus, and resulting recommendation grades of the recom- In all patients with lung cancer the smoking status should be es- mendations of this guideline. The recommendation grades A–D tablished and documented (A). are added to the recommendations in the abridged version. For All smoking patients with lung cancer should be motivated to the evidence levels, see the full version [1]. quit smoking. They should be offered participation in a qualified For the preparation of this guideline the 6th edition of the TNM smoking-cessation program (A). classification and staging system of UICC (International Union The implementation of workplace protection provisions and reg- Against Cancer) was used which was valid until Dec 31, 2009. ulations, as required by law, together with continuous scientific The changes in the classification and staging system carried out review and risk assessment of hazardous substances, minimizes in the 7th edition, valid from Jan 01, 2010, are presented in chap- the risks from carcinogenic pollutants in the workplace (A). ter 5 (Diagnosis) of the full version of the guideline. The changes To minimize the risk of lung cancer from exposure to radon gas in the 7th edition of the UICC classification [4] result in an the exposure to radon gas in homes must be consequently re- amendment in chapter 6 (Treatment of non-small cell lung carci- duced through adequate technical measures (A). noma) and in the algorithm for the treatment of non-small cell During the indication for medical application of ionizing radia- lung cancer in stage IIIB (●" Fig. 7), where subgroup T4N0/1M0 tion it is mandatory to weigh the benefits of its use against the no longer belongs to stage IIIB – as in the 6th edition –, but to potential risks of radiation exposure (A). stage IIIA. The recommendations for the therapeutic approach in The lung cancer risk from air pollutants can be most effectively subgroup T4N0/1M0 are not affected by the change in classifica- reduced by reducing the emission of diesel exhaust particles (A). tion. A diet that is rich in fruits, fresh vegetables, and tomatoes re- In this abridged version the recommendations of the guideline duced the risk of lung cancer in several clinical trials and is there- are summarized. The full version of the guideline has been pub- fore recommended (C). lished in printed form (Pneumologie 2010; 64, Supplement 2: Primary or secondary prevention by medication cannot be re- S23–S155) and electronic form (http://dx.doi.org/10.1055/s- commended outside of clinical studies (A). 0029-1243837). The electronic version includes the bibliography and appendices (occupational history form, evidence tables, ad- dendum and guideline report). Table 1 Relationship between levels of evidence and grades of recommendation (modified according to Oxford Center for Evidence-based Medicine 2001 [2] and AWMF [3]). Evidence Evidence Consensus Grade of recommendation Level Therapy Diagnosis Modifying criteria for recommendation 1a Systematic Review (SR) of SR of Level 1 diagnostic studies A Strong recommendation Randomized Controlled – Ethical aspects Clinical Trials (RCTs) – Patient preferences 1b Individual RCT (with narrow Validating cohort study with – Clinical relevance, integrated confidence interval) good reference standards outcome 1c All or none Absolute specifity for ruling – Clinically significant in or absolute sensitivity for deviation from study ruling out the diagnosis situation 2a SR of cohort studies SR of Level > 2 diagnostic studies B Moderate recommendation 2b Individual cohort study, Exploratory cohort study with low quality RCT good reference standards 2c “Outcomes” Research 3a SR of case-control studies SR of non-consecutive studies 3b Individual case-control study Non-consecutive study 4 Case-series, poor quality Case-control study, poor or C Weak recommendation cohort and case-control non-independent reference – Studies: consistency, studies standard effectiveness 5 Expert opinion without Expert opinion without critical D Missing or inconsistent – Benefits,risks,sideeffects critical appraisal, or based appraisal, or based studies, recommendation – Applicability on physiology etc. on physiology etc. based on expert opinion Goeckenjan G et al. Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer… Pneumologie 2011; 65: 39 –59 Guideline 41 4 Early Detection of Lung Cancer 5 Diagnosis of Lung Cancer ! ! No clinical benefit of screening chest radiographs for the early Initial evaluation detection of asymptomatic lung cancer, even in high-risk persons In patients with suspected or known lung cancer a careful clinical (e.g. smokers, asbestos exposure) has been established. Thus evaluation including history and physical examination is strongly screening for lung cancer by chest radiographs in asymptomatic recommended (A). persons is not recommended (A). It is strongly recommended that a patient with known lung can- No clinical benefit of screening CT scans for the early detection of cer and a paraneoplastic syndrome is not precluded from poten- asymptomatic lung cancer has been established up to now. Thus tially curative therapy on the basis of these symptoms alone (A). screening for lung cancer by CT scans in asymptomatic persons is not recommended either (B). Diagnosis All asymptomatic persons insisting on CT scans for lung cancer Chest X-ray examination (p.a. and lateral projections) is strongly screening should be given the opportunity to be included in a recommended as initial radiological procedure (A). prospective, well designed, controlled, randomized clinical trial In patients suspected of having lung cancer who are eligible for (D). treatment a CT scan of the chest is strongly recommended, since Based upon the clinical evidence available screening for lung can- the potential benefits outweigh the relatively low risk of a radia- cer by sputum cytologic evaluation is not recommended (A). tion-induced damage (A). Because of its invasive nature bronchoscopy is not suitable for the Bronchoscopy represents the most important method of confir- early diagnosis of lung cancer in
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