Lung Cancer: Diagnosis and Management in Secondary Care

Overview

This specialist Guidelines summary covers diagnosing and managing non-small-cell and small-cell lung cancer. It aims to improve outcomes for patients by ensuring that the most effective tests and treatments are used, and that people have access to suitable follow-up. It is intended for use by clinical and medical oncologists and radiologists in a secondary care setting.

Please refer to the full guideline for information on access to services and referral.

A table of NHS England interim treatment regimens gives possible alternative treatment options for use during the COVID-19 pandemic to reduce infection risk. This may affect decisions for patients with lung cancer. See the COVID-19 rapid guideline: delivery of systemic anticancer treatments for more details.

Reflect on your learning and download our Reflection Record

Communication

Helping People Understand Their Condition and the Tests and Treatments Available

• Find out what the person knows about their condition without assuming a level of knowledge. Provide them with the opportunity to discuss tests and treatment options in a private environment, with the support of family members or carers (as appropriate), and give them time to make an informed choice
• Ensure that a lung cancer clinical nurse specialist is available at all stages of care to support people and (as appropriate) their family members or carers
• Offer accurate and easy-to-understand information to people and their family members or carers (as appropriate). Explain the tests and treatment options, including potential survival benefits, side effects and effect on symptoms
• Consider tailor-made decision aids to help people to:
  • understand the probable outcomes of treatment options
  • think about the personal value they place on benefits versus harms of treatment options
  • feel supported in decision making
  • move through the steps towards making a decision
  • take part in decisions about their healthcare
• Offer people a record of all discussions that have taken place with them and a copy of any correspondence with other healthcare professionals. Ensure all communications are worded in such a way to assist understanding
• Respect the person's choice if they do not wish to confront future issues
• Avoid giving people unexpected bad news in writing. Only give unexpected bad news by phone in exceptional circumstances
• Offer to discuss end-of-life care with the person sensitively and when appropriate. Wherever possible, avoid leaving this discussion until the terminal stages of the illness
• Document discussions with the person about end-of-life care. In particular, document:
  • their specific concerns
  • their understanding of their illness and its prognosis
  • important values or personal goals for care
  • their preferences for the types of care or treatment that may be beneficial in the future and their availability
• Share information between healthcare professionals about:
  • any problems the person has
  • the management plan
  • what the person has been told
  • what the person has understood (if possible)
  • the involvement of other agencies
  • any advance decision made by the person.

Diagnosis and Staging

Effectiveness of Diagnostic and Staging Investigations

• Only use sputum cytology for investigation in people with suspected lung cancer who have centrally placed nodules or masses and who decline or cannot tolerate bronchoscopy or other invasive tests
• Offer people with known or suspected lung cancer a contrast-enhanced chest computed tomography (CT) scan to further the diagnosis and stage the disease. Include the liver, adrenals, and lower neck in the scan. The guideline committee also recognised that contrast medium should only be given with caution to people with known renal impairment
• When assessing mediastinal and chest wall invasion:
  • be aware that CT alone may not be reliable
  • consider other techniques such as ultrasound if there is doubt
  • be aware that surgical assessment may be necessary if there are no contraindications to resection
• Ensure that all people with lung cancer who could potentially have treatment with curative intent are offered positron-emission tomography CT (PET–CT) before treatment
• Every cancer alliance should have a system of rapid access to PET–CT scanning for eligible people
• Do not routinely use magnetic resonance imaging (MRI) to assess the stage of the primary tumour (T-stage) in non-small-cell lung cancer (NSCLC)
• Use MRI when necessary to assess the extent of disease, for people with superior sulcus tumours
• Offer endobronchial ultrasound-guided transbronchial needle aspiration (EBUS–TBNA) for biopsy of paratracheal and peri-bronchial intra-parenchymal lung lesions
• Every cancer alliance should have at least 1 centre with EBUS and/or endoscopic ultrasound (EUS) to ensure timely access
• Audit the local test performance of EBUS–TBNA and EUS-guided fine-needle aspiration (FNA)
• When taking samples, ensure they are adequate (without unacceptable risk to the person) to permit pathological diagnosis, including tumour subtyping and assessment of predictive markers
• For guidance on epidermal growth factor receptor tyrosine kinase (EGFR-TK) mutation testing, see the NICE diagnostics guidance on EGFR-TK mutation testing in adults with locally advanced or metastatic non-small-cell lung cancer.

Sequence of Investigations

• Choose investigations that give the most information about diagnosis and staging with the least risk to the person. Think carefully before performing a test that gives only diagnostic pathology when information on staging is also needed to guide treatment
• Perform contrast-enhanced CT of the chest, liver, adrenals, and lower neck before any biopsy procedure.

Peripheral Primary Tumour

• Offer image-guided biopsy to people with peripheral lung lesions when treatment can be planned on the basis of this test
• Biopsy any enlarged intrathoracic nodes (10 mm or larger maximum short axis on CT) or other lesions in preference to the primary lesion if determination of nodal stage affects treatment. Some people with lung cancer will not be well enough for treatment with curative intent. This needs to be taken into account when choosing diagnostic and staging investigations.

Central Primary Tumour

• Offer flexible bronchoscopy to people with central lesions on CT if nodal staging does not influence treatment.

Intrathoracic Lymph Node Assessment

• Offer PET–CT as the preferred first test after CT with a low probability of nodal malignancy (lymph nodes below 10 mm maximum short axis on CT) for people with lung cancer who could potentially have treatment with curative intent
• Offer PET–CT (if not already done), followed by EBUS–TBNA and/or EUS–FNA, to people with suspected lung cancer who have enlarged intrathoracic lymph nodes (lymph nodes greater than or equal to 10 mm short axis on CT) and who could potentially have treatment with curative intent
• Evaluate PET–CT-positive or enlarged intrathoracic nodes using a systematic approach (sampling any suspicious node on CT, PET, or ultrasonography) with EBUS–TBNA and/or EUS–FNA if nodal status would affect the treatment plan
• Consider surgical mediastinal staging for people with a negative EBUS–TBNA or EUS–FNA if clinical suspicion of nodal malignancy is high and nodal status would affect their treatment plan.

NICE have produced an algorithm on intrathoracic nodal staging of non-small cell lung cancer in patients being considered for radical treatment.

Future Staging

• Confirm the presence of isolated distant metastases/synchronous tumours by biopsy or further imaging (for example, MRI or PET–CT) in people being considered for treatment with curative intent
• Do not offer dedicated brain imaging to people with clinical stage I NSCLC who have no neurological symptoms and are having treatment with curative intent
• Offer contrast-enhanced brain CT to people with clinical stage II NSCLC who are having treatment with curative intent. If CT shows suspected brain metastases, offer contrast-enhanced brain MRI
• Offer contrast-enhanced brain MRI for people with stage III NSCLC who are having treatment with curative intent
• Offer people with clinical features suggestive of intracranial pathology CT of the head followed by MRI if normal, or MRI as an initial test
• Perform an X-ray as the first test for people with localised signs or symptoms of bone metastasis. If the results are negative or inconclusive, offer bone scintigraphy or an MRI scan
• Avoid bone scintigraphy when PET–CT has not shown bone metastases.

Organisational Factors Relevant to Diagnosis and Staging

• Provide treatment without undue delay for people who have lung cancer that is suitable for radical treatment or chemotherapy, or who need radiotherapy or ablative treatment for relief of symptoms.

Multidisciplinary Teams

• Refer all people with a suspected diagnosis of lung cancer to a member of a lung cancer multidisciplinary team (usually a chest physician)
• The care of all people with a working diagnosis of lung cancer should be discussed at a lung cancer multidisciplinary team meeting. 

Fast Track Lung Clinics

• Provide fast-track lung cancer clinics (previously known as early diagnosis clinics and rapid access clinics) for investigating suspected lung cancer, because they are associated with faster diagnosis and less anxiety. 

Cancer Clinical Nurse Specialists

• All cancer units/centres should have one or more trained lung cancer clinical nurse specialists to:
  • see people before, at the time of, and after diagnosis
  • provide continuing support
  • facilitate communication between the secondary care team (including the multidisciplinary team), the person's GP, the community team, and the person with lung cancer
  • help people access advice and support whenever they need it.

Treatment

Stop Smoking Interventions and Services

• Inform people that smoking increases the risk of pulmonary complications after lung cancer surgery
• Advise people to stop smoking as soon as the diagnosis of lung cancer is suspected and tell them why this is important
• Offer nicotine replacement therapy and other therapies to help people to stop smoking in line with the NICE guideline on tobacco: preventing uptake, promoting quitting and treating dependence and the NICE technology appraisal guidance on varenicline for smoking cessation
• Do not postpone surgery for lung cancer to allow people to stop smoking.

Assessing People with Non-small-cell Lung Cancer for Treatment With Curative Intent

Perioperative Mortality

• When evaluating surgery as an option for people with NSCLC, consider using a global risk score such as Thoracoscore to estimate the risk of death. Ensure the person is aware of the risk before they give consent for surgery.

Cardiovascular Function

• Avoid surgery within 30 days of myocardial infarction
• Seek a cardiology review in people with an active cardiac condition, or 3 or more risk factors, or poor cardiac functional capacity
• Offer surgery without further investigations to people with 2 or fewer risk factors and good cardiac functional capacity
• Optimise any primary cardiac treatment and begin secondary prophylaxis for coronary disease as soon as possible
• Continue anti-ischaemic treatment in the perioperative period, including aspirin, statins, and beta-blockers
• For people with coronary stents, discuss perioperative anti-platelet treatment with a cardiologist
• Consider revascularisation (percutaneous intervention or coronary artery bypass grafting) before surgery for people with chronic stable angina and conventional indications for revascularisation.

Lung Function

• Perform spirometry and transfer factor (TLCO) in all people being considered for treatment with curative intent
• Offer people surgery if they have a forced expiratory volume in 1 second (FEV1) within normal limits and good exercise tolerance
• When considering surgery, perform a functional segment count to predict postoperative lung function
• Offer people with predicted postoperative FEV1 or TLCO below 30% the option of treatment with curative intent if they accept the risks of dyspnoea and associated complications
• Consider using shuttle walk testing (using a distance walked of more than 400 m as a cut-off for good function) to assess the fitness of people with moderate to high risk of postoperative dyspnoea
• Consider cardiopulmonary exercise testing to measure oxygen uptake (VO₂ max) and assess lung function in people with moderate to high risk of postoperative dyspnoea, using more than 15 ml/kg/minute as a cut-off for good function.

Assessment Before Radiotherapy with Curative Intent

• A clinical oncologist specialising in thoracic oncology should determine suitability for radiotherapy with curative intent, taking into account performance status and comorbidities.

Surgery and Radiotherapy with Curative Intent for Non-small-cell Lung Cancer

Surgery

• For people with NSCLC who are well enough and for whom treatment with curative intent is suitable, offer lobectomy (either open or thoracoscopic)
• Offer more extensive surgery (bronchoangioplastic surgery, bilobectomy, pneumonectomy) only when needed to obtain clear margins
• Perform hilar and mediastinal lymph node sampling or en bloc resection for all people having surgery with curative intent
• For people with T3 NSCLC with chest wall involvement who are having surgery, aim for complete resection of the tumour using either extrapleural or en bloc chest wall resection.

Surgery or Radiotherapy for People Not Having Lobectomy

• For people with stage I–IIA (T1–T2b, N0, M0) NSCLC who decline lobectomy or in whom it is contraindicated, offer radical radiotherapy with stereotactic ablative radiotherapy (SABR) or sublobar resection.

Radical Radiotherapy for People Not Having Surgery

• All people should have pulmonary function tests (including lung volumes and transfer factor) before radical radiotherapy for NSCLC
• People receiving radiotherapy with curative intent should be part of a national quality assurance programme
• For people with stage I–IIA (T1a–T2b, N0, M0) NSCLC who decline surgery or in whom any surgery is contraindicated, offer SABR. If SABR is contraindicated, offer either conventional or hyperfractionated radiotherapy
• For eligible people with stage IIIA NSCLC who cannot tolerate or who decline chemoradiotherapy (with or without surgery), consider radical radiotherapy (either conventional or hyperfractionated)
• For eligible people with stage IIIB NSCLC who cannot tolerate or who decline chemoradiotherapy, consider radical radiotherapy (either conventional or hyperfractionated).

Radiotherapy fractionation

• If using SABR, follow the SABR Consortium guidance on fractionation
• If conventionally fractionated radical radiotherapy is used, offer either:
  • 55 Gy in 20 fractions over 4 weeks, or
  • 60–66 Gy in 30–33 fractions over 6–6½ weeks.

Combination Treatment for Non-small-cell Lung Cancer

• Consider chemoradiotherapy for people with stage II or III NSCLC that are not suitable for or decline surgery. Balance potential benefit in survival with the risk of additional toxicities
• Ensure that all people for whom multimodality treatment is potentially suitable (surgery, radiotherapy, and chemotherapy in any combination) are assessed by a thoracic oncologist and by a thoracic surgeon
• Offer postoperative chemotherapy to people with good performance status (WHO 0 or 1) and T1a–4, N1–2, M0 NSCLC
• Consider postoperative chemotherapy for people with good performance status (WHO 0 or 1) and T2b–4, N0, M0 NSCLC with tumours greater than 4 cm in diameter
• Offer a cisplatin-based combination chemotherapy regimen for adjuvant chemotherapy
• For people with stage I–II NSCLC that are suitable for surgery, do not offer neo-adjuvant treatment outside a clinical trial
• Ensure eligible people have the benefit of detailed discussion of the risks and benefits of adjuvant chemotherapy
• Treat Pancoast tumours in the same way as other types of NSCLC. Offer multimodality therapy according to resectability, stage of the tumour, and performance status of the person
• For people with operable stage IIIA–N2 NSCLC who can have surgery and are well enough for multimodality therapy, consider chemoradiotherapy with surgery
• Discuss the benefits and risks with the person before starting chemoradiotherapy with surgery, including that:
  • chemoradiotherapy with surgery improves progression-free survival
  • chemoradiotherapy with surgery may improve overall survival
• For people with stage IIIA–N2 NSCLC who are having chemoradiotherapy and surgery, ensure that their surgery is scheduled for 3 to 5 weeks after the chemoradiotherapy
• Multidisciplinary teams that provide chemoradiotherapy with surgery should have expertise in the combined therapy and in all of the individual components
• Centres performing lung resections for lung cancer should validate their data for the Royal College of Physicians Lung Cancer Clinical Outcomes publication and the National Lung Cancer Audit.

Systemic Anti-cancer Therapy for Advanced Non-small-cell Lung Cancer

NICE has produced treatment pathways bringing together NICE recommended treatment options from this guideline and relevant technology appraisal guidance on advanced non-small-cell lung cancer (squamous and non-squamous). The treatment pathways cover the recommended treatment options at each decision point. These are available to view as individual pathways, or grouped together in a single interactive PDF of all treatment pathways for squamous and non-squamous advanced non-small-cell lung cancer.

Assessing People with Small-cell Lung Cancer

• Arrange for people with small-cell lung cancer (SCLC) to have an assessment by a thoracic oncologist within 1 week of deciding to recommend treatment.

First Line Treatment for Limited-stage Disease Small-cell Lung Cancer

• Offer people with limited-stage disease SCLC (broadly corresponding to T1–4, N0–3, M0) 4 to 6 cycles of cisplatin-based combination chemotherapy. Consider substituting carboplatin in people with impaired renal function, poor performance status (WHO 2 or more), or significant comorbidity
• Offer twice-daily radiotherapy with concurrent chemotherapy to people with limited-stage disease SCLC (broadly corresponding to T1–4, N0–3, M0) and a WHO performance status of 0 or 1, if they present with disease that can be encompassed in a radical thoracic radiotherapy volume. Start the radiotherapy during the first or second cycle of chemotherapy
• If the person declines or is unable to have twice-daily radiotherapy, offer once-daily radiotherapy
• Offer sequential radical thoracic radiotherapy to people with limited-stage disease SCLC (broadly corresponding to T1–4, N0–3, M0) who are not well enough for concurrent chemoradiotherapy but who respond to chemotherapy
• Offer prophylactic cranial irradiation at a dose of 25 Gy in 10 fractions to people with limited-stage disease SCLC and WHO performance status 0 to 2, if their disease has not progressed on first-line treatment.

Surgery for Small-cell Lung Cancer

• Consider surgery in people with early-stage SCLC (T1–2a, N0, M0).

First-line Treatment for Extensive-stage Disease Small-cell Lung Cancer

• Offer platinum-based combination chemotherapy to people with extensive-stage disease SCLC (broadly corresponding to T1–4, N0–3, M1a/b—including cerebral metastases) if they are fit enough
• Assess the person's condition before each cycle of chemotherapy for extensive-stage disease SCLC (broadly corresponding to T1–4, N0–3, M1a/b) and offer up to a maximum of 6 cycles, depending on response and toxicity
• Consider thoracic radiotherapy with prophylactic cranial irradiation for people with extensive-stage disease SCLC who have had a partial or complete response to chemotherapy within the thorax and at distant sites
• Consider prophylactic cranial irradiation for people with extensive-stage disease SCLC and WHO performance status 0 to 2, if their disease has responded to first-line treatment.

Maintenance Treatment for Small-cell Lung Cancer

• Only offer maintenance treatment to people with SCLC in the context of a clinical trial.

Second-line Treatment for Small-cell Lung Cancer That has Relapsed After First-line Treatment

• Offer people with SCLC that has relapsed after first-line treatment assessment by a thoracic oncologist
• Inform people whose disease has not responded to first-line treatment that there is very limited evidence that second-line chemotherapy will be of benefit
• Offer people with relapsed SCLC in whom chemotherapy is suitable treatment with an anthracycline-containing regimen or further treatment with a platinum-based regimen to a maximum of 6 cycles
• Offer radiotherapy for palliation of local symptoms to people with SCLC that has relapsed after first-line treatment.

Topotecan

• Refer to the NICE technology appraisal guidance on topotecan for the treatment of relapsed small-cell lung cancer.

Please refer to the full guideline for more information on Palliative Interventions and Supportive and Palliative Care.

Follow-up and Patient Perspectives

Organising Follow-up and Collecting Information on Patient Experience

• Offer all people with lung cancer an initial specialist follow-up appointment within 6 weeks of completing treatment to discuss ongoing care. Offer regular appointments after this, rather than relying on the person requesting appointments when they experience symptoms
• Offer protocol-driven follow-up led by a lung cancer clinical nurse specialist as an option for people with a life expectancy of more than 3 months
• Ensure that people know how to contact the lung cancer clinical nurse specialist involved in their care between their scheduled hospital visits
• The opinions and experiences of people with lung cancer and their family members or carers (as appropriate) should be collected and used to improve the delivery of lung cancer services. People should receive feedback on any action taken as a result of such surveys.