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The Diagnosis and Treatment of Lung Cancer the Diagnosis and Treatment of Lung Cancer Treatment Lung of and Diagnosis the METHODS, EVIDENCE & GUIDANCE

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The Diagnosis and Treatment of Lung Cancer the Diagnosis and Treatment of Lung Cancer Treatment Lung of and Diagnosis the METHODS, EVIDENCE & GUIDANCE National Collaborating Centre for Acute Care The Diagnosis and Treatment of Lung Cancer The Diagnosis and of Lung Treatment Cancer METHODS, EVIDENCE & GUIDANCE FEBRUARY 2005 Commissioned by the National Institute for Clinical Excellence i The Diagnosis and Treatment of Lung Cancer METHODS, EVIDENCE & GUIDANCE ii THE DIAGNOSIS AND TREATMENT OF LUNG CANCER iii Published by the National Collaborating Centre for Acute Care at The Royal College of Surgeons of England, 35-43 Lincoln’s Inn Fields, London, WC2A 3PE First published 2005 © National Collaborating Centre for Acute Care 2005 Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use. The rights of National Collaborating Centre for Acute Care to be identified as Author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988. ISBN 0-9549760-0-2 Citing this document: National Collaborating Centre for Acute Care, February 2005. Diagnosis and treatment of lung cancer. National Collaborating Centre for Acute Care, London. Available from www.rcseng.ac.uk iv LUNG CANCER CONTENTS v Foreword Contents Lung cancer remains the UK’s commonest cause of cancer death. It is now over 50 years since Sir Richard Doll’s seminal paper linked GUIDELINE DEVELOPMENT GROUP 3.3 PATIENT DELAY IN PRESENTATION TO tobacco smoking to lung cancer. Although tobacco consumption has fallen overall since then, with a resultant fall in the male MEMBERSHIP & ACKNOWLEDGEMENTS VIII GENERAL PRACTITIONERS 27 incidence of lung cancer, smoking has increased in women, having the effect of increased lung cancer in females. Tobacco control 3.4 KEY SYMPTOMS AND SIGNS 28 remains the crucial factor in reducing future lung cancer rates. 3.5 RECOMMENDATIONS 29 STAKEHOLDER INVOLVEMENT X It is clear to everyone involved in lung cancer care that the public concept of this disease is characterised by much negativity. There 4 DIAGNOSIS 31 is too much emphasis generally on the relatively poor outcomes of treatment, there is a lack of sympathy for the patients deemed to ABBREVIATIONS XII have brought the disease on themselves through tobacco use, and there is an impression which is unwarranted, that some 4.1 INTRODUCTION 31 professionals have a nihilistic attitude about the treatment of lung cancer patients. There are few patient advocates, and the disease 4.2 TECHNIQUES INCLUDED IN THIS REVIEW 31 has a low public profile in respect of media coverage, general awareness and research funding. GLOSSARY OF TERMS XIV 4.3 METHODOLOGY 31 4.4 IMAGING 32 However, in reviewing the research, and preparing this guideline, the Development Group were encouraged by many positive 4.5 TISSUE CONFIRMATION 34 developments such as the emergence of the lung cancer specialist nurse service, the creation of Lung Cancer Multi-Disciplinary 1 INTRODUCTION 1 4.6 ECONOMICS OF DIAGNOSIS OF LUNG CANCER 38 teams, and the improvement in the evidence base for treatment, especially chemotherapy. We would also wish to highlight 1.1 BACKGROUND 1 4.7 RECOMMENDATIONS 42 developments in technology, such as FDG-PET scanning in disease staging and the use of the CHART regimen for the delivery of 1.2 WHAT IS A GUIDELINE?2 radical radiotherapy in suitable patients. 1.3 REMIT OF THE GUIDELINE 2 5 STAGING OF LUNG CANCER 43 1.4 WHAT THE GUIDELINE COVERS 2 The Development Group were charged to consider “the diagnosis and treatment of lung cancer”. This is a huge topic overall. To 5.1 INTRODUCTION 43 1.5 WHAT THE GUIDELINE DOES NOT COVER 3 consider every nuance of presentation and management in this guideline would have been a formidable and impossible task. We 5.2 TECHNIQUESINCLUDEDINTHISREVIEW 43 have not set out to write a text book of lung cancer care. Rather, we have attempted to review the main outlines of lung cancer 1.6 COLLABORATION WITH THE SCOTTISH 5.3 METHODOLOGY 43 presentation, diagnosis and treatment, with particular emphasis on areas where there has been new evidence, or, where it seems to INTERCOLLEGIATE GUIDELINE NETWORK 3 5.4 STAGING CLASSIFICATIONS 43 us, carefully evaluated guidance, which will improve patient care. 1.7 WHO DEVELOPED THE GUIDELINE?3 5.5 T-STAGE ASSESSMENT 44 1.8 SUMMARY OF THE RECOMMENDATIONS AND 5.6 N-STAGE ASSESSMENT 45 It has been a difficult decision for the group as to which aspects to include, which to omit and which to highlight. It has been particularly THE ALGORITHM 4 5.7 M-STAGE ASSESSMENT 49 difficult too to narrow down our original 94 recommendations to 10 key items, which we believe if implemented, will have the greatest 5.8 STAGING OF SMALL CELL LUNG CANCER 52 impact on patient outcomes. We hope however that the research review in this document and the conclusions we have drawn from it will 2 METHODOLOGY 21 continue the improvements which are taking place in the care of patients with this common and important disease. 5.9 ECONOMICS OF LUNG CANCER STAGING 53 2.1 GUIDELINE METHODOLOGY 21 5.10 RECOMMENDATIONS 58 Jesme Baird, 2.2 REVIEW OF THE CLINICAL LITERATURE 21 Chair, Guideline Development Group. 2.3 HIERARCHY OF CLINICAL EVIDENCE 22 6 SURGERY WITH CURATIVE INTENT 2.4 HEALTH ECONOMICS METHODS 24 FOR PATIENTS WITH NON-SMALL 2.5 FORMING AND GRADING THE RECOMMENDATIONS 25 CELL LUNG CANCER 60 6.1 INTRODUCTION 60 3 ACCESS TO SERVICES 27 6.2 TECHNIQUES INCLUDED IN THIS REVIEW 60 3.1 INTRODUCTION 27 6.3 METHODOLOGY 60 3.2 METHODOLOGY 27 6.4 PREOPERATIVE SELECTION OF PATIENTS WITH NON SMALL CELL LUNG CANCER FOR SURGERY 60 vi LUNG CANCER CONTENTS vii 6.5 RISK OF SURGERY 60 8.2 THE DRUGS INCLUDED IN THIS REVIEW 83 10 ENDOBRONCHIAL TREATMENT AS 12.7 M ANAGEMENT OF HOARSENESS 131 6.6 SURGERY FOR STAGE I 8.3 METHODOLOGY 83 RADICAL TREATMENT FOR NON 12.8 C HEST PAIN 131 NON SMALL CELL LUNG CANCER 61 8.4 PATIENT ELIGIBILITY 84 SMALL CELL LUNG CANCER 105 12.9 S UPERIOR VENA CAVA OBSTRUCTION 131 6.7 SURGERY FOR STAGE II 8.5 CHEMOTHERAPY + ACTIVE SUPPORTIVE 12.10 M ANAGEMENT OF BRAIN METASTASES 132 10.1 INTRODUCTION 105 NON SMALL CELL LUNG CANCER (N1 DISEASE)65 CARE (ASC) VERSUS ASC 84 12.11 S PINAL CORD COMPRESSION 133 10.2 TECHNIQUES INCLUDED IN THIS REVIEW 105 6.8 SURGERY FOR STAGE IIB-IIIA 8.6 SECOND GENERATION VERSUS 12.12 H YPERCALCAEMIA, BONE PAIN AND 10.3 METHODOLOGY 105 NON SMALL CELL LUNG CANCER (T3 DISEASE)67 THIRD GENERATION REGIMENS 85 PATHOLOGICAL FRACTURES 134 10.4 PHOTODYNAMIC THERAPY 105 6.9 SURGERY FOR STAGE IIIA 8.7 CARBOPLATIN VERSUS CISPLATIN 85 12.13 OTHER SYMPTOMS: WEIGHT LOSS, LOSS OF APPETITE, 10.5 BRACHYTHERAPY 106 NON SMALL CELL LUNG CANCER (N2 DISEASE)68 8.8 THIRD GENERATION CHEMOTHERAPY TREATMENT 85 DIFFICULTY SWALLOWING, FATIGUE AND DEPRESSION 135 10.6 ELECTROCAUTERY 106 6.10 SURGERY FOR STAGE IIIB (N3 AND T4 DISEASE) 8.9 DURATION OF THERAPY IN ADVANCED 12.14 E CONOMICS OF PALLIATIVE INTERVENTIONS 136 10.7 CRYOTHERAPY 107 NON SMALL CELL LUNG CANCER 70 NON SMALL CELL LUNG CANCER 86 12.15 R ECOMMENDATIONS 138 10.8 ND YAG LASER ABLATION 107 6.11 ECONOMICSOFSURGERYFORNON SMALL CELL 8.10 DOSAGE OF CHEMOTHERAPY TREATMENT 87 10.9 ECONOMICS OF ENDOBRONCHIAL THERAPY FOR LUNG CANCER 71 8.11 SECOND-LINE CHEMOTHERAPY IN 13 SERVICE ORGANISATION 140 NON SMALL CELL LUNG CANCER 107 6.12 RECOMMENDATIONS 72 NON SMALL CELL LUNG CANCER 87 10.10 RECOMMENDATIONS 107 13.1 INTRODUCTION 140 8.12 ECONOMICS OF CHEMOTHERAPY FOR 13.2 ISSUES EXAMINED IN THIS REVIEW 140 7 RADICAL RADIOTHERAPY ALONE NON SMALL CELL LUNG CANCER 87 11 TREATMENT OF SMALL CELL LUNG CANCER 109 13.3 METHODOLOGY 140 FOR TREATMENT OF NON-SMALL 8.13 CONCLUSIONS 94 13.4 MULTI- DISCIPLINARY TEAMS (MDTS)140 CELL LUNG CANCER 74 8.14 RECOMMENDATIONS 94 11.1 I NTRODUCTION 109 13.5 EARLY DIAGNOSIS CLINICS 141 11. 2 T REATMENT TECHNIQUES INCLUDED IN THIS REVIEW 109 7.1 INTRODUCTION 74 13.6 SPECIALIST NURSE SUPPORT 141 9 COMBINATION TREATMENT FOR 11. 3 M ETHODOLOGY 109 7.2 TECHNIQUES INCLUDED IN THIS REVIEW 74 13.7 TIMING OF TREATMENT 142 NON SMALL CELL LUNG CANCER 95 11. 4 P ATIENT ELIGIBILITY 109 7.3 METHODOLOGY 75 13.8 FOLLOW UP 143 11. 5 C HEMOTHERAPY 110 7.4 ASSESSMENT OF PATIENTS FOR RADICAL RADIOTHERAPY 75 9.1 INTRODUCTION 95 13.9 THE PATIENT’S PERSPECTIVE 147 11. 6 R ADIOTHERAPY 113 7.5 RADICAL RADIOTHERAPY FOR STAGE I AND 9.2 TECHNIQUES INCLUDED IN THIS REVIEW 96 13.10 RECOMMENDATIONS 149 11. 7 S URGERY FOR PATIENTS WITH SCLC 116 II MEDICALLY INOPERABLE NON SMALL CELL 9.3 METHODOLOGY 96 11. 8 E CONOMICS OF THE TREATMENT OF SCLC 116 LUNG CANCER PATIENTS 75 9.4 PREOPERATIVE CHEMOTHERAPY 96 14 PRIORITY AREAS FOR AUDIT 150 11. 9 R ECOMMENDATIONS 118 7.6 TREATMENT OF STAGE IIIA AND IIIB NON 9.5 POSTOPERATIVE CHEMOTHERAPY 97 SMALL CELL LUNG CANCER PATIENTS 77 9.6 PREOPERATIVE RADIOTHERAPY 98 12 PALLIATIVE INTERVENTIONS AND 15 BIBLIOGRAPHY 153 7.7 ECONOMICS OF RADICAL RADIOTHERAPY FOR 9.7 POSTOPERATIVE RADIOTHERAPY 98 SUPPORTIVE AND PALLIATIVE CARE 120 NON SMALL CELL LUNG CANCER 80 9.8 POSTOPERATIVE CHEMORADIOTHERAPY 99 7.8 CONCLUSION 81 9.9 PRIMARY CHEMORADIOTHERAPY FOR INOPERABLE 12.1 I NTRODUCTION 120 Appendicies 1-8, including the evidence tables, are on the 7.9 RECOMMENDATIONS 82 NON SMALL CELL LUNG CANCER 99 12.2 TOOLSINCLUDEDINTHISREVIEW 122 attached CD-ROM.
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