Appendix 10 Lung cancer: the diagnosis and treatment of lung cancer (2005) – including the original sections of the guideline that have been updated by the 2011 document. The diagnosis and treatment of lung cancer (update): full guideline (April 2011) Appendix 10 Page 1 of 208 Foreword 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 tobacco smoking to lung cancer. Although tobacco consumption has fallen overall since then, with a resultant fall in the male incidence of lung cancer, smoking has increased in women, having the effect of increased lung cancer in females. Tobacco control remains the crucial factor in reducing future lung cancer rates. It is clear to everyone involved in lung cancer care that the public concept of this disease is characterised by much negativity. There is too much emphasis generally on the relatively poor outcomes of treatment, there is a lack of sympathy for the patients deemed to have brought the disease on themselves through tobacco use, and there is an impression which is unwarranted, that some professionals have a nihilistic attitude about the treatment of lung cancer patients. There are few patient advocates, and the disease has a low public profile in respect of media coverage, general awareness and research funding. However, in reviewing the research, and preparing this guideline, the Development Group were encouraged by many positive developments such as the emergence of the lung cancer specialist nurse service, the creation of Lung Cancer Multi-Disciplinary teams, and the iprovement in the evidence base for treatment, especially chemotherapy. We would also wish to highlight developments in technology, such as FDG-PET scanning in disease staging and the use of the CHART regimen for the delivery of radical radiotherapy in suitable patients. The Development Group were charged to consider ―the diagnosis and treatment of lung cancer‖. This is a huge topic overall. To consider every nuance of presentation and management in this guideline would have been a formidable and impossible task. We 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 presentation, diagnosis and treatment, with particular emphasis on areas where there has been new evidence, or, where it seems to us, carefully evaluated guidance, which will improve patient care. 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 difficult too to narrow down our original 94 recommendations to 10 key items, which we believe if implemented, will have the greatest impact on patient outcomes. We hope however that the research review in this document and the conclusions we have drawn from it will continue the improvements which are taking place in the care of patients with this common and important disease. Jesme Baird, Chair, Guideline Development Group. The diagnosis and treatment of lung cancer (update): full guideline (April 2011) Appendix 10 Page 2 of 208 Contents 1 INTRODUCTION 1 1.1 BACKGROUND 1 1.2 WHAT IS A GUIDELINE? 2 1.3 REMIT OF THE GUIDELINE 2 1.4 WHAT THE GUIDELINE COVERS 2 1.5 WHAT THE GUIDELINE DOES NOT COVER 3 1.6 COLLABORATION WITH THE SCOTTISH INTERCOLLEGIATE GUIDELINE NETWORK 3 1.7 WHO DEVELOPED THE GUIDELINE? 3 1.8 SUMMARY OF THE RECOMMENDATIONS AND THE ALGORITHM 4 2 METHODOLOGY 21 2.1 GUIDELINE METHODOLOGY 21 2.2 REVIEW OF THE CLINICAL LITERATURE 21 2.3 HIERARCHY OF CLINICAL EVIDENCE 22 2.4 HEALTH ECONOMICS METHODS 24 2.5 FORMING AND GRADING THE RECOMMENDATIONS 25 3 ACCESS TO SERVICES 27 3.1 INTRODUCTION 27 3.2 METHODOLOGY 27 3.3 PATIENT DELAY IN PRESENTATION TO GENERAL PRACTITIONERS 27 3.4 KEY SYMPTOMS AND SIGNS 28 3.5 RECOMMENDATIONS 29 4 DIAGNOSIS 31 4.1 INTRODUCTION 31 4.2 TECHNIQUES INCLUDED IN THIS REVIEW 31 4.3 METHODOLOGY 31 4.4 IMAGING 32 4.5 TISSUE CONFIRMATION 34 4.6 ECONOMICS OF DIAGNOSIS OF LUNG CANCER 38 4.7 RECOMMENDATIONS 42 5 STAGING OF LUNG CANCER 43 5.1 INTRODUCTION 43 5.2 TECHNIQUES INCLUDED IN THIS REVIEW 43 5.3 METHODOLOGY 43 5.4 STAGING CLASSIFICATIONS 43 5.5 T-STAGE ASSESSMENT 44 5.6 N-STAGE ASSESSMENT 45 5.7 M-STAGE ASSESSMENT 49 5.8 STAGING OF SMALL CELL LUNG CANCER 52 5.9 ECONOMICS OF LUNG CANCER STAGING 53 5.10 RECOMMENDATIONS 58 6 SURGERY WITH CURATIVE INTENT FOR PATIENTS WITH NON-SMALL CELL LUNG CANCER 60 6.1 INTRODUCTION 60 6.2 TECHNIQUES INCLUDED IN THIS REVIEW 60 6.3 METHODOLOGY 60 6.4 PREOPERATIVE SELECTION OF PATIENTS WITH NON SMALL CELL LUNG CANCER FOR SURGERY 60 6.5 RISK OF SURGERY 60 6.6 SURGERY FOR STAGE I NON SMALL CELL LUNG CANCER 61 6.7 SURGERY FOR STAGE II NON SMALL CELL LUNG CANCER (N1 DISEASE) 65 6.8 SURGERY FOR STAGE IIB-IIIA NON SMALL CELL LUNG CANCER (T3 DISEASE) 67 6.9 SURGERY FOR STAGE IIIA NON SMALL CELL LUNG CANCER (N2 DISEASE) 68 6.10 SURGERY FOR STAGE IIIB (N3 AND T4 DISEASE) NON SMALL CELL LUNG The diagnosis and treatment of lung cancer (update): full guideline (April 2011) Appendix 10 Page 3 of 208 CANCER 70 6.11 ECONOMICS OF SURGERY FOR NON SMALL CELL LUNG CANCER 71 6.12 RECOMMENDATIONS 72 7 RADICAL RADIOTHERAPY ALONE FOR TREATMENT OF NON-SMALL CELL LUNG CANCER 74 7.1 INTRODUCTION 74 7.2 TECHNIQUES INCLUDED IN THIS REVIEW 74 7.3 METHODOLOGY 75 7.4 ASSESSMENT OF PATIENTS FOR RADICAL RADIOTHERAPY 75 7.5 RADICAL RADIOTHERAPY FOR STAGE I AND II MEDICALLY INOPERABLE NON SMALL CELL LUNG CANCER PATIENTS 75 7.6 TREATMENT OF STAGE IIIA AND IIIB NON SMALL CELL LUNG CANCER PATIENTS 77 7.7 ECONOMICS OF RADICAL RADIOTHERAPY FOR NON SMALL CELL LUNG CANCER 80 7.8 CONCLUSION 81 7.9 RECOMMENDATIONS 82 8 CHEMOTHERAPY FOR NON SMALL CELL LUNG CANCER 83 8.1 INTRODUCTION 83 8.2 THE DRUGS INCLUDED IN THIS REVIEW 83 8.3 METHODOLOGY 83 8.4 PATIENT ELIGIBILITY 84 8.5 CHEMOTHERAPY + ACTIVE SUPPORTIVE CARE (ASC) VERSUS ASC 84 8.6 SECOND GENERATION VERSUS THIRD GENERATION REGIMENS 85 8.7 CARBOPLATIN VERSUS CISPLATIN 85 8.8 THIRD GENERATION CHEMOTHERAPY TREATMENT 85 8.9 DURATION OF THERAPY IN ADVANCED NON SMALL CELL LUNG CANCER 86 8.10 DOSAGE OF CHEMOTHERAPY TREATMENT 87 8.11 SECOND-LINE CHEMOTHERAPY IN NON SMALL CELL LUNG CANCER 87 8.12 ECONOMICS OF CHEMOTHERAPY FOR NON SMALL CELL LUNG CANCER 87 8.13 CONCLUSIONS 94 8.14 RECOMMENDATIONS 94 9 COMBINATION TREATMENT FOR NON SMALL CELL LUNG CANCER 95 9.1 INTRODUCTION 95 9.2 TECHNIQUES INCLUDED IN THIS REVIEW 96 9.3 METHODOLOGY 96 9.4 PREOPERATIVE CHEMOTHERAPY 96 9.5 POSTOPERATIVE CHEMOTHERAPY 97 9.6 PREOPERATIVE RADIOTHERAPY 98 9.7 POSTOPERATIVE RADIOTHERAPY 98 9.8 POSTOPERATIVE CHEMORADIOTHERAPY 99 9.9 PRIMARY CHEMORADIOTHERAPY FOR INOPERABLE NON SMALL CELL LUNG CANCER 99 9.10 PANCOAST TUMOURS 101 9.11 ECONOMICS OF COMBINATION TREATMENT FOR NON SMALL CELL LUNG CANCER 102 9.12 RECOMMENDATIONS 104 10 ENDOBRONCHIAL TREATMENT AS RADICAL TREATMENT FOR NON SMALL CELL LUNG CANCER 105 10.1 INTRODUCTION 105 10.2 TECHNIQUES INCLUDED IN THIS REVIEW 105 10.3 METHODOLOGY 105 10.4 PHOTODYNAMIC THERAPY 105 10.5 BRACHYTHERAPY 106 10.6 ELECTROCAUTERY 106 The diagnosis and treatment of lung cancer (update): full guideline (April 2011) Appendix 10 Page 4 of 208 10.7 CRYOTHERAPY 107 10.8 ND YAG LASER ABLATION 107 10.9 ECONOMICS OF ENDOBRONCHIAL THERAPY FOR NON SMALL CELL LUNG CANCER 107 10.10 RECOMMENDATIONS 107 11 TREATMENT OF SMALL CELL LUNG CANCER 109 11.1 INTRODUCTION 109 11.2 TREATMENT TECHNIQUES INCLUDED IN THIS REVIEW 1 09 11.3 METHODOLOGY 109 11.4 PATIENT ELIGIBILITY 109 11.5 CHEMOTHERAPY 110 11.6 RADIOTHERAPY 113 11.7 SURGERY FOR PATIENTS WITH SCLC 116 11.8 ECONOMICS OF THE TREATMENT OF SCLC 116 11.9 RECOMMENDATIONS 118 12 PALLIATIVE INTERVENTIONS AND SUPPORTIVE AND PALLIATIVE CARE 1 20 12.1 INTRODUCTION 120 12.2 TOOLS INCLUDED IN THIS REVIEW 122 12.3 METHODOLOGY 123 12.4 COMMUNICATION 123 12.5 MANAGEMENT OF DYSPNOEA (BREATHLESSNESS) 127 12.6 MANAGEMENT OF COUGH 130 12.7 MANAGEMENT OF HOARSENESS 131 12.8 CHEST PAIN 131 12.9 SUPERIOR VENA CAVA OBSTRUCTION 131 12.10 MANAGEMENT OF BRAIN METASTASES 132 12.11 SPINAL CORD COMPRESSION 133 12.12 HYPERCALCAEMIA, BONE PAIN AND PATHOLOGICAL FRACTURES 134 12.13 OTHER SYMPTOMS: WEIGHT LOSS, LOSS OF APPETITE, DIFFICULTY SWALLOWING, FATIGUE AND DEPRESSION 135 12.14 ECONOMICS OF PALLIATIVE INTERVENTIONS 136 12.15 RECOMMENDATIONS 138 13 SERVICE ORGANISATION 140 13.1 INTRODUCTION 140 13.2 ISSUES EXAMINED IN THIS REVIEW 140 13.3 METHODOLOGY 140 13.4 MULTI- DISCIPLINARY TEAMS (MDTS) 140 13.5 EARLY DIAGNOSIS CLINICS 141 13.6 SPECIALIST NURSE SUPPORT 141 13.7 TIMING OF TREATMENT 142 13.8 FOLLOW UP 143 13.9 THE PATIENT‘S PERSPECTIVE 147 13.10 RECOMMENDATIONS 149 14 PRIORITY AREAS FOR AUDIT 150 15 BIBLIOGRAPHY 153 The diagnosis and treatment of lung cancer (update): full guideline (April 2011) Appendix 10 Page 5 of 208 Stakeholder Involvement The following stakeholders registered with NICE and were invited to comment on draft versions of these guidelines: The diagnosis and treatment of lung cancer (update): full guideline (April 2011) Appendix 10 Page 6 of 208 Abbott Laboratories Limited (BASF/Knoll) College of Occupational Therapists Action on Smoking and Health (ASH) Countess of Chester Hospitals NHS Trust Afiya Trust, The Craven Harrogate & Rural District PCT Aintree Hospitals NHS Trust Department of Health Airedale General Hospital Eisai Limited Amersham Health Elan Pharmaceuticals Ltd Amgen UK Ltd Eli Lilly and Company Ltd Anglesey Local Health Board Faculty of Public Health Association for Palliative Medicine of Great Gateshead Health NHS Trust Britain and Ireland GE Health