Irish Medical News


Diagnosing lung cancer: Guideline update


The long-awaited updated guidance on diagnosing lung cancer was released last week by the National Institute for Clinical Excellence (NICE) in the UK, replacing previous recommendations published in 2005.


“This updated guideline contains a number of new recommendations reflecting up-to-date developments since the original guideline was published, which include the diagnosis and staging of the disease, different approaches to treatment – including offering surgery to those patients who are medically-fit and suitable – and a new emphasis on follow-up,” Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE, told IMN.
The guideline also builds on previous recommendations around supporting the patient, including a new section on communication.

“Lung cancer is the second most common form of cancer in Ireland and the UK and the leading cause of death from cancer – more people now die as a result of it than breast cancer and colorectal cancer. The aim of this guideline is to help ensure patients across the country are diagnosed quickly and accurately and receive the best possible care,” explained Dr Macbeth.

New and updated recommendations are included on 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 SCLC, managing endobronchial obstruction, managing brain metastases, and follow-up and patient perspectives.

Since publication of the NICE clinical guideline in 2005, the new document states a number of new systemic therapies have been granted a marketing authorisation by the European Medicines Agency (EMEA) for use in people with NSCLC. NICE has also published technology appraisals for pemetrexed, gefitinib and erlotinib, and other technology appraisals are in development.

Updated recommendations include:

• Communication: Ensure that a lung cancer clinical nurse specialist is available at all stages of care to support patients and carers.

• 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.

• Surgery with curative intent for NSCLC: Offer patients with NSCLC who are medically-fit and suitable for treatment with curative intent lobectomy as the treatment of first choice. For patients with borderline fitness and smaller tumours, consider lung parenchymal-sparing operations if a complete resection can be achieved.

• 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.

• Follow-up and patient perspectives: Offer all patients an initial specialist follow-up appointment within six weeks of completing treatment to discuss ongoing care. Offer regular appointments thereafter, rather than relying on patients requesting appointments when they experience symptoms.

“We know that the frequency with which treatments, such as surgery and chemotherapy, are offered to patients with lung cancer can vary quite markedly depending on location or what services are locally available… we need to ensure the same high standard is applied wherever people live. This guideline clearly sets out what healthcare professionals should do and what patients should expect from them,” said Dr Macbeth.
The recommendations show that Ireland’s  lung cancer services are above par, as they already emphasise the importance of rapid access clinics, which already exist across the country.

Diagnosis and staging

• Offer patients with known or suspected lung cancer a contrast-enhanced CT scan of the chest liver and adrenals.

• Biopsy enlarged mediastinal nodes (10 mm maximum short axis on CT) or other lesions in preference to primary lesion if determination of stage affects treatment.

• Every cancer clinic should have rapid access to PET-CT scanning.

• Ensure all patients potentially suitable for treatment with curative intent are offered PET-CT before treatment.

• Reserve sputum cytology for patients with centrally placed nodules or masses who are unable to tolerate bronchoscopy or other invasive tests.

• Do not use MRI routinely to stage the primary tumour in NSCLC.

Effective communication

•Document discussions with the patient about end-of-life care, particularly about the patient’s specific concerns, their understanding of the prognosis, and important values and preferences for care and treatment.

• Share information between healthcare professionals about the management plan, what the patient has been told and has understood, any problems, any advance decision and the involvement of other agencies.

• Send a copy of the radiologist’s report to a designated member of the lung cancer multi-disciplinary team (MDT) (usually the chest physician) when a chest X-ray incidentally suggests lung cancer. Ensure the MDT has a mechanism for following up these reports with the patient’s GP.

• Discuss care of patients with a working diagnosis of lung cancer at a lung cancer MDT meeting.

• Find out what the patient knows about their condition without assuming a level of knowledge.

• Offer accurate and easy-to-understand information and ensure all communications are worded to assist understanding.

• Explain treatment options (including potential survival benefits, side effects and effect on symptoms) in a private environment, with the support of carers and the time to make an informed choice.

• Consider tailor-made decision aids to help patients understand probable outcomes, weigh up possible benefits and harms and make decisions about treatments.

• Offer patients a record of all discussions and a copy of correspondence with other healthcare professionals, but avoid giving bad news by letter.

• Only give bad news by phone in exceptional circumstances.

• When appropriate, sensitively offer to discuss end-of-life care. If possible, avoid leaving this until the terminal stages, but respect the patient’s choice if they do not wish to confront future issues. n


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