Apply NICE’s Treatment Pathways for Lung Cancer Within Your Local Framework

Professor Michael D Peake OBE Examines the Recommendations in the Updated NICE Guideline on Lung Cancer, and Assesses How its Implementation May Be Affected by Factors Not Addressed in the Guidance

Introduction

Lung cancer remains the UK’s biggest cancer killer, and was responsible for nearly 35,000 deaths per year in the UK between 2017 and 2019.¹ The disease accounts for 13% of all new cases of cancer in the UK, and is the cause of 21% of all cancer‑related deaths—around 95 people die from lung cancer in the UK every day.¹ Although the majority of cases are caused by smoking, around 10–15% of people who develop lung cancer in the UK are never smokers. If considered as a separate entity, lung cancer in never-smokers is the eighth most common cause of cancer-related death in the UK. ²

Before the onset of the Covid-19 pandemic, survival rates in lung cancer were generally improving,^3–5 although they remained lower than those of other comparable countries.⁶ However, COVID-19 has had a devastating impact on lung cancer pathways, treatments, and survival, and previous hard-won gains in improving outcomes are now in jeopardy, with thousands of additional lung cancer deaths anticipated as a result of the pandemic.^2,4,7

What’s New in the Updated NICE Guideline?

The NICE Guideline (NG) on lung cancer (NG 122) was updated in August 2022, following its publication in 2019.⁸ In a departure from its usual approach, NICE has provided comprehensive visual algorithms, showing 19 different treatment pathways for treating advanced non-small-cell lung cancer (NSCLC) based on individual tumour biomarkers.⁸ The treatment pathways bring together NICE guidance and previous technology appraisal recommendations on advanced non-small-cell lung cancer treatment options, reflecting current clinical practice, and highlighting NHS England commissioning decisions.

Previously, this information was presented both in separate visual summaries, and as recommendations within the guideline. In the 2022 update, the recommendations are incorporated into the separate treatment pathways.⁸ This is a presentational change only, and the recommendations still apply. The treatment pathways were developed with expert input, and cover the treatment options at each decision point.

Based on the 2019 evidence review, and to reflect current best practice, recommendations integrated into treatment pathways in 2022 include:

• recommendations on the use of contrast-enhanced computed tomography (CT) chest scan in diagnosis and staging, suggesting it should be performed before any biopsy procedure, and on auditing the local test performance of endobronchial ultrasound‑guided transbronchial needle aspiration (EBUS‑TBNA) and endoscopic ultrasound guided fine needle aspiration (EUS-FNA)
• image guided biopsy in peripheral lung lesions, when treatment can be planned on the basis of this test
• recommendations on rapid access to positron emission tomography (PET-CT) and brain imaging for lung cancer staging
• prophylactic cranial irradiation, radical radiotherapy, and operable stage IIIA disease.⁸

The recommendations in the guideline are mainly focussed on secondary and tertiary care, although the guidance is of relevance to any stakeholder with an interest in lung cancer, including non-specialists and those working in primary care.
Apart from the alterations to the presentation of algorithms for the treatment pathway, the 2022 version is largely unchanged, and this article therefore also focuses on recommendations published in 2019. These are explored in more detail in the following sections.^8–10

Diagnosis and Staging

After initial imaging with CT, the majority of patients with a radiological diagnosis of lung cancer will require further investigations to assess the stage of their disease and the histology of the tumour, to identify any actionable mutations and its PD-L1 status in order to decide which treatment options are best. Minimising the number of steps in the diagnosis and staging pathway—and completing them efficiently—will reduce delays in treatment.

The NICE guideline clarifies when to use positron emission tomography (PET)‑CT, EBUS‑TBNA, EUS-FNA, and surgical staging.

The guideline no longer recommends using non‑ultrasound‑guided TBNA. It also states that people with stage‑II or -III NSCLC who are being considered for curative treatment should receive brain imaging before treatment begins—the presence of brain metastases may modify their management plan.⁸

Treatment of Stage-I–III NSCLC

The guideline states that lobectomy remains the treatment of choice for stage‑I and ‑II NSCLC.⁸ Although recent data challenge this, the recommendation remains unchanged.^11,12

Data show that 45% of people with NSCLC treated with lobectomy are still alive 5 years post‑surgery.¹⁰ For patients not undergoing surgical resection, the guidance recommends stereotactic ablative radiotherapy (SABR) as a treatment option for primary lung tumours ≤5 cm in diameter without evidence of metastatic spread.⁸

SABR uses multiple small high precision beams of radiation from different angles, which limits any damage to other normal tissue. A complete course of SABR can be delivered in many fewer hospital visits, compared to conventional fractionation schedules.

For patients not undergoing surgical resection or SABR, the guideline recommends conventional or hyperfractionated radiotherapy schedules, and does not distinguish between the two.⁹ Centres with suitable expertise should consider offering neo-adjuvant chemoradiotherapy and surgery to patients with operable stage‑IIIA N2 NSCLC, a patient group for whom the optimal management strategy has been extensively debated in the literature.¹³ The guideline also recognises that SABR has a place in the treatment of patients with oligometastatic disease.⁸

Systemic Treatment of Advanced NSCLC

Clinical trials have demonstrated that people with advanced and ‘incurable’ NSCLC may benefit from systemic anticancer treatment (SACT), which can improve their quality of life and extend survival.⁸ A large number of new SACT drugs have been developed and approved over the past decade, many of which have undergone independent technology appraisals by NICE advisory committees.

The guideline also includes two algorithms for people diagnosed with stage‑IIIB and ‑IV NSCLC based on patient tumour histology and biomarkers (squamous and non-squamous NSCLC). Innovations in this area are frequent, and the pathway will be updated periodically on the NICE website.⁸

Treatment for SCLC

Combination chemotherapy continues to be the first‑line treatment for patients with SCLC.⁸ Brain metastases are common and, in the past, it was recommended that prophylactic whole‑brain radiotherapy should be offered to patients without brain metastases who respond to first‑line chemotherapy. However, confidence in the survival benefits associated with this strategy in people with advanced disease has decreased, and the recommendation for prophylactic cranial irradiation in patients with SCLC is to 'consider' rather than 'offer'.^8,14,15 In addition, clinicians should consider thoracic radiotherapy in patients who respond to chemotherapy and receive prophylactic cranial irradiation.⁸ Centres should offer twice‑daily chemoradiotherapy for patients with limited‑stage SCLC, rather than once‑daily chemoradiotherapy.

Quality Standard

In December 2019, as an adjunct to its update to the guideline at that time, NICE also revised its Quality Standard, Lung cancer in adults (see Box 1).¹⁶ This Quality Standard was expected to contribute to improvements in the following outcomes:

• lung cancer diagnoses at stages I or II
• 1- and 5-year lung cancer survival rates
• lung cancer mortality rate
• health-related quality of life in adults with lung cancer
• satisfaction with care in adults with lung cancer.

Although updates and additions are welcomed, and it is vital to have ambitious targets to improve outcomes and bring survival rates in line with those of other cancer types, many of the statements did not take into account significant issues such as funding, data collection, treatment access, and workforce.

For example, in terms of public awareness (Statement 1), Cancer Alliances have many competing calls on their budgets, and few are currently running localised public awareness campaigns. However, some national campaigns continue on an intermittent basis. With regard to smoking cessation (Statement 2), both community-and hospital-based services are limited in many areas and many, if not most, will struggle to meet this target.¹⁶

Access to a named lung cancer nurse specialist (LCNS) is welcome (Statement 3), because patients are more likely to have a good experience of care and receive active treatment when seen by an LCNS. However, most areas of the country continue to have numbers of LCNSs well below that proposed in the national commissioning guidance of one whole-time equivalent LCNS per 80 new cases per year.¹⁷ LCNSs are also being asked to take on basic nursing duties in many areas, further limiting their capacity to meet this standard.

In theory, most patients will have access to all the necessary investigations outlined in Statement 4.¹⁶ However, the most common problem is timeliness.

What is Not Covered in the Guideline?

Among the areas that the guidance doesn’t address are:

• surgery: video-assisted thoracoscopic surgery versus open lung resection
• mesothelioma
• immunotherapy after chemoradiotherapy for non-resectable N2 NSCLC.

The guideline also fails to acknowledge issues around workforce shortages, which are a major limitation to improving lung cancer outcomes across the entire pathway. Some groups have called upon the Government to provide a multi-year funding settlement to support a comprehensive plan to grow the NHS workforce across specialties.^18,19

UK governments should invest in the training and upskilling of existing support staff and assistant practitioners to enable them to perform tasks and free-up other team members to undertake more specialised tasks. The NLCA recently carried out an organisational audit to identify what would be required.²⁰

Screening and other methods of achieving earlier diagnosis is a key area that is also not covered in the updated guideline. Late diagnosis is the main reason why long-term outcomes in lung cancer remain poor.²¹ Lung cancer screening will do more to improve UK lung cancer survival than any other single intervention. Evidence of the effectiveness of lung cancer screening is strong, and the emergence of screening programmes, such as the Targeted Lung Health Check Pilot Programme in certain locations in England, is likely to have a major long-term impact on survival and mortality rates.²² Despite this, implementation of lung cancer screening programmes has been slow across the UK, and a governmental approach is overdue. In response, the National Screening Committee's Consultation has been looking at targeted screening of lung cancer in people aged 55–74 who have a history of smoking, with an expectation that the findings will soon be published.²³ However, given staff shortages in radiology, will there be sufficient radiologists available to undertake CT screening for patients, should it receive approval in the UK?

There also continue to be significant delays in turnaround times for PET–CT scanning, EBUS, and molecular pathology services; in a bid to tackle this, the UK government has announced new community diagnostic centres. These centres aim to provide quicker diagnoses to patients, and to help with dealing with the backlog caused by the Covid-19 pandemic. Despite this, the appropriateness and quality of biopsies taken for molecular diagnostic purposes also varies a great deal around the country.^16,17 

Conclusion

Local commissioning structures offer flexibility but have the potential to increase variation and inequalities if evidence‑based standards for services are not applied. Thus, national guidance must be followed, but local flexibility should be employed to implement the guideline within the local healthcare landscape.

Outcomes for people with lung cancer are improving, but there remains much work to do, particularly given the impact of the pandemic. Achieving universal, timely access to optimal care will result in a major improvement in outcomes—both in terms of survival and quality of life—for people with lung cancer. In addition, a decision by the UK National Screening Committee on lung cancer screening is keenly awaited.²⁴ The current national campaign by the patient group Roy Castle on the importance of screening for lung cancer (#needtoscreen) is helping to increase awareness of this, along with a renewed focus from NHS England on public awareness of the symptoms of lung cancer.^25,26

Professor Michael D Peake OBE is Co-Clinical Director for the Centre for Cancer Outcomes, University College London Hospitals, founder and Board member of the UK Lung Cancer Coalition, and Honorary Professor of Respiratory Medicine at the University of Leicester

This is an update of an article first published in Specialised Medicine (Peake M. February 2020; 4 (1): 17–20).

Coming soon: An analysis of guidance focused on achieving better outcomes in lung cancer post-COVID.