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Lung cancer
Implementing NICE guidance
2nd. edition - April 2012
NICE clinical guideline 121
Updated guidance
This guideline updates and replaces ‘Lung cancer’
(NICE clinical guideline 24, 2005)
New and updated recommendations cover :
• diagnosis and staging
• selection of patients with NSCLC for treatment with curative intent
• surgery with curative intent for NSCLC
• combination treatment for NSCLC
• treatment for SCLC
• managing endobronchial obstruction
• managing brain metastases
• communication, smoking cessation, follow-up,
patient perspectives
What this presentation covers
Background
Key recommendations
Costs and savings
Discussion
NICE Pathway
NHS Evidence
Find out more
NICE Quality Standard for lung cancer
Background
• There are more than 39,000 new cases of lung cancer
in the UK each year
• Only about 5.5% of lung cancers are currently cured
• About 90% of lung cancers are caused by smoking
Recommendations
The guideline makes recommendations in the following areas
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Access to services and referral
Communication
Diagnosis and staging
Smoking cessation
Treatment for NSCLC and SCLC
Palliative care
Follow-up and patient perspectives
Access to services and referral
Coordinate campaigns to raise awareness of symptoms
Urgently refer patients presenting with symptoms of lung cancer
for a chest X-ray
If a chest X-ray or CT scan suggests lung cancer (or is normal
but lung cancer is still suspected), urgently refer the patient to a
member of the lung cancer MDT (usually the chest physician)
Communication
Ensure that a lung cancer clinical nurse specialist is available at all
stages of care to support patients and carers
Offer patients information, a record of all discussions and a copy of all
correspondence
Respect the patient’s choice if they do not wish to confront future issues
Avoid giving unexpected bad news by letter or phone
Sensitively offer to discuss end-of-life care when appropriate, and
ensure discussions are documented
Diagnosis and stagingeffectiveness of investigations
Choose investigations that give the most information with least risk to
the patient
Offer all patients with known or suspected lung cancer a contrastenhanced chest CT scan
Chest CT should be performed before any biopsy procedure
Diagnosis and stagingsequence of investigations
Biopsy enlarged mediastinal nodes or other lesions in preference to the
primary lesion if determination of stage affects treatment
Offer PET-CT, or EBUS-guided TBNA, or EUS-guided FNA, or nonultrasound-guided TBNA after CT showing an intermediate probability of
mediastinal malignancy for patients potentially suitable for treatment with
curative intent
Confirm negative results obtained by other tests by surgical staging if
clinical suspicion remains high
Treatment - smoking cessation
Advise patients to stop smoking as soon as the diagnosis of lung
cancer is suspected
Offer nicotine replacement therapy and other therapies
Do not postpone surgery to allow patients to stop smoking, but do
inform them that smoking increases the risk of pulmonary
complications after lung cancer surgery
NSCLC - selection of patients
for treatment with curative intent
Consider using a risk score to estimate the risk of perioperative death
Take into account the patient’s cardiovascular function when considering
surgery
Measure and take into account the patient’s lung function when
considering treatment with curative intent
A clinical oncologist should determine suitability for radiotherapy with
curative intent
Treatment with curative intent
for patients with NSCLC
All patients potentially suitable for multimodality treatment should
be assessed by a thoracic oncologist and a thoracic surgeon
If suitable, offer patients a lobectomy as the treatment of first choice
Consider radiotherapy with curative intent for patients with stage I, II
or III NSCLC and good performance status
Offer the CHART regimen to patients with:
•stage I or II NSCLC who are medically inoperable
•stage IIIA or IIIB NSCLC who cannot or do not wish to have
chemoradiotherapy
Treatment for patients with
SCLC
Patients with SCLC should be assessed by a thoracic oncologist within 1
week of deciding to treat
Offer patients with limited-stage disease, cisplatin-based chemotherapy with:
• concurrent radiotherapy if they are fit and their disease is
encompassed in a radical radiotherapy volume, or
• sequential radiotherapy if they are unfit for concurrent
chemoradiotherapy but respond to chemotherapy
Consider surgery for patients with early-stage disease
Offer patients with extensive-stage disease platinum-based combination
chemotherapy
Palliative interventions
and care
Supportive and palliative care should be provided by general and
specialist palliative care providers and patients who may benefit
from specialist palliative care should be referred without delay
Palliative radiotherapy and other treatments should be given as
necessary
Patients with endobronchial obstruction should have rapid
access to a team capable of providing interventional
endobronchial treatments
Follow-up and patient
perspectives
Offer all patients an initial specialist follow-up appointment within
6 weeks of completing treatment and regular appointments
thereafter
Ensure that patients know how to contact the lung cancer clinical
nurse specialist between appointments
Collect feedback on patient experiences and use it to improve
future services
Costs per 100,000 population
Recommendations with significant costs
Costs
(£ per year)
Offer EBUS-guided TBNA for biopsy of paratracheal and
peri-bronchial intra-parenchymal lung lesions and during
mediastinal lymph node assessment
2,730
Select patients with NSCLC for treatment with curative
intent – assess lung function
7,560
Follow-up appointments and patient perspective
Palliative interventions – managing endobronchial
obstructions
Estimated cost of implementation
Costs correct at April 2011.
Costs not updated for 2nd edition
of the slide set.
781
4,362
15,434
Discussion
• What are we doing to raise awareness of the symptoms of
lung cancer?
• Are we thinking enough about the information we need for
diagnosis, staging and subsequent treatments before
recommending investigations?
• Do we have rapid access to a team capable of providing
interventional endobronchial treatments?
• Is a lung cancer clinical nurse specialist available at all stages
of care to support patients and carers? What are our current
arrangements for follow-up?
NICE Pathway
The NICE lung
cancer Pathway
covers the
diagnosis and
treatment of lung
cancer.
Click here to go to
NICE Pathways
website
NHS Evidence
Visit NHS Evidence
for the best
available evidence
on all aspects of
lung cancer
Click here to go to
the NHS Evidence
website
Find out more
Visit www.nice.org.uk/guidance/CG121for:
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the guideline
the quick reference guide
‘Understanding NICE guidance’
costing report and template
audit support and baseline assessment tool
Quality standard
This section of the slide set summarises the quality
standard for lung cancer. The full quality standard can
be found on the NICE website:
http://www.nice.org.uk/guidance/qualitystandards/lungca
ncer/home.jsp
The quality standard includes 15 markers of high-quality,
cost-effective care for people with lung cancer based on
recommendations in NICE guidance.
Quality statement 1:
Public awareness
People are made aware of the symptoms and signs of
lung cancer through local coordinated public awareness
campaigns that result in early presentation.
Quality measure
Structure: Evidence of local arrangements to ensure that people are
made aware of the symptoms and signs of lung cancer through local
coordinated public awareness campaigns that result in early
presentation.
Process: Proportion of people newly diagnosed with lung cancer who
were identified as a result of a local public awareness campaign.
Quality statement 2:
Referral for chest X-ray
People reporting one or more symptoms suggesting lung
cancer are referred within 1 week of presentation for a
chest X-ray or directly to a chest physician who is a core
member of the lung cancer multidisciplinary team.
Quality measure
Structure: Evidence of local arrangements and written clinical protocols to ensure
that people reporting one or more symptoms suggesting lung cancer are referred
within 1 week of presentation for a chest X-ray or directly to a chest physician who is
a core member of the lung cancer multidisciplinary team.
Process:
a) Proportion of people reporting one or more symptoms suggesting lung cancer
who are referred within 1 week of presentation for a chest X-ray or directly to a
chest physician who is a core member of the lung cancer multidisciplinary team.
b) Proportion of people with lung cancer who saw their GP about symptoms
suggesting lung cancer no more than twice in the last 6 months before referral
for a chest X-ray or directly to a chest physician who is a core member of the
lung cancer multidisciplinary team.
Quality statement 3:
Chest X-ray report
People with a chest X-ray result suggesting lung cancer
have a copy of the radiologist’s report sent to and
followed up by the lung cancer multidisciplinary team.
Quality measure
Structure: Evidence of local arrangements and written clinical
protocols for people with a chest X-ray result suggesting lung cancer
to have a copy of the radiologist’s report sent to and followed up by the
lung cancer multidisciplinary team.
Process: Proportion of people with a chest X-ray result suggesting
lung cancer who have a copy of the radiologist’s report sent to and
followed up by the lung cancer multidisciplinary team.
Quality statement 4: Lung cancer
clinical nurse specialist
People with known or suspected lung cancer have
access to a named lung cancer clinical nurse specialist
who they can contact between scheduled hospital visits.
Quality measure
Structure: Evidence of local arrangements and written clinical protocols to
ensure that people with known or suspected lung cancer have access to a
named lung cancer clinical nurse specialist who they can contact between
scheduled hospital visits.
Process:
a) Proportion of people with known or suspected lung cancer who have been
given the name and contact number of a lung cancer clinical nurse
specialist who they can contact between scheduled hospital visits.
b) Proportion of people with lung cancer who had a lung cancer clinical nurse
specialist present at diagnosis.
c) Proportion of people with lung cancer who have been assessed by a lung
cancer clinical nurse specialist.
Quality statement 5:
Holistic needs assessment
People with lung cancer are offered a holistic needs
assessment at each key stage of care that informs their
care plan and the need for referral to specialist services.
Quality measure
Structure: Evidence of local arrangements and written clinical protocols to
ensure that people with lung cancer are offered a holistic needs assessment at
each key stage of care that informs their care plan and the need for referral to
specialist services.
Process:
a) Proportion of people with lung cancer who have a care plan based on a
holistic needs assessment undertaken at diagnosis.
b) Proportion of people with lung cancer who have a care plan based on a
holistic needs assessment undertaken at diagnosis and other key stages
of care.
c) Proportion of people with lung cancer who receive specialist services as a
result of a care plan based on a holistic needs assessment.
Quality statement 6:
Investigations
People with lung cancer, following initial assessment
and computed tomography (CT) scan, are offered
investigations that give the most information about
diagnosis and staging with the least risk of harm.
Quality measure
Structure: Evidence of local arrangements and written clinical
protocols to ensure that people with lung cancer following initial
assessment and CT scan are offered investigations that give the most
information about diagnosis and staging with the least risk of harm.
Process:
a) Proportion of people with lung cancer following initial assessment
and CT scan who have pathologically confirmed mediastinal
staging.
b) Proportion of people with lung cancer following initial assessment
and CT scan who receive two or more invasive tests for diagnostic
and staging purposes.
Quality statement 7:
Tissue diagnosis
People with lung cancer have adequate tissue samples
taken in a suitable form to provide a complete pathological
diagnosis including tumour typing and sub-typing, and
analysis of predictive markers.
Quality measure
Structure: Evidence of local arrangements and written clinical protocols
to ensure that people with lung cancer have adequate tissue samples
taken in a suitable form to provide a complete pathological diagnosis
including tumour typing and sub-typing, and analysis of predictive
markers.
Process: see next slide
Quality statement 7:
Tissue diagnosis (continued)
Quality measure - continued
Process:
a) Proportion of people with lung cancer who have a second
diagnostic test in order to obtain additional pathological information.
b) Proportion of people with lung cancer who have a pathological
diagnosis.
c) Proportion of people with lung cancer who have a tumour type
identified.
d) Proportion of people with non-small-cell lung cancer who have a
tumour sub-type identified.
e) Proportion of people with non-small-cell lung cancer where reported
tumour sub-type is ‘not otherwise specified’.
f) Proportion of people with lung cancer who have an analysis of
predictive markers.
Quality statement 8:
Curative treatment in people
of borderline fitness
People with resectable lung cancer who are of borderline
fitness and not initially accepted for surgery are offered the
choice of a second surgical opinion, and a multidisciplinary
team opinion on non-surgical treatment with curative intent.
Quality measure
Structure: Evidence of local arrangements and written clinical protocols to ensure
that people with resectable lung cancer who are of borderline fitness and not initially
accepted for surgery are offered the choice of a second surgical opinion, and a
multidisciplinary team opinion on non-surgical treatment with curative intent.
Process:
a) Proportion of people with resectable lung cancer who are of borderline fitness
and not initially accepted for surgery who are offered the choice of a second
surgical opinion, and a multidisciplinary team opinion on non-surgical treatment
with curative intent.
b) Proportion of people with resectable lung cancer who are of borderline fitness
and not initially accepted for surgery who receive non-surgical treatment with
curative intent.
Quality statement 9: Access to
specialist assessment
People with lung cancer are offered assessment for
multimodality treatment by a multidisciplinary team
comprising all specialist core members.
Quality measure
Structure: Evidence of local arrangements and written clinical protocols to
ensure that people with lung cancer are offered assessment for
multimodality treatment by a multidisciplinary team comprising all
specialist core members.
Process: Proportion of people with lung cancer who receive assessment
for multimodality treatment by a multidisciplinary team comprising all
specialist core members.
Quality statement 10:
Access to radiotherapy
People with lung cancer stage I–III and good
performance status who are unable to undergo surgery
are assessed for radiotherapy with curative intent by a
clinical oncologist specialising in thoracic oncology.
Quality measure
Structure: Evidence of local arrangements and written clinical protocols to
ensure that people with lung cancer stage I–III and good performance
status who are unable to undergo surgery are assessed for radiotherapy
with curative intent by a clinical oncologist specialising in thoracic
oncology.
Process: Proportion of people with lung cancer stage I–III and good
performance status who are assessed for radiotherapy with curative intent
by a clinical oncologist specialising in thoracic oncology.
Quality statement 11:
Optimal radiotherapy
People with lung cancer stage I–III and good
performance status who are offered radiotherapy with
curative intent receive planned treatment techniques that
optimise the dose to the tumour while minimising the
risks of normal tissue damage.
Quality measure
Structure: Evidence of local arrangements and written clinical protocols to ensure
that people with lung cancer stage I–III and good performance status who are
offered radiotherapy with curative intent receive planned treatment techniques that
optimise the dose to the tumour while minimising the risks of normal tissue damage.
Process:
a) Proportion of people with lung cancer stage I–III and good performance status
who receive radiotherapy with curative intent.
b) Proportion of people with lung cancer receiving radiotherapy with curative intent
who receive planned treatment techniques that optimise the dose to the tumour
while minimising the risks of normal tissue damage.
Quality statement 12:
Systemic therapy for advanced
non-small-cell lung cancer
People with stage IIIB or IV non-small-cell lung cancer and
eligible performance status are offered systemic therapy
(first- and second-line) in accordance with NICE guidance,
that is tailored to the pathological sub-type of the tumour and
individual predictive factors.
Quality measure
Structure: Evidence of local arrangements and written clinical protocols to ensure that
people with stage IIIB or IV non-small-cell lung cancer and eligible performance status are
offered systemic therapy (first- and second-line) in accordance with NICE guidance, that is
tailored to the pathological sub-type of the tumour and individual predictive factors.
Process:
a) Proportion of people with stage IIIB or IV non-small-cell lung cancer and eligible
performance status who receive first-line systemic therapy in accordance with NICE
guidance, that is tailored to the pathological sub-type of the tumour and individual
predictive factors.
b) Proportion of people with advanced stage IIIB or IV non-small-cell lung cancer and
eligible performance status who receive second-line systemic therapy in accordance with
NICE guidance, that is tailored to the pathological sub-type of the tumour and individual
predictive factors.
Quality statement 13:
Small-cell lung cancer
People with small-cell lung cancer have treatment
initiated within 2 weeks of the pathological diagnosis.
Quality measure
Structure: Evidence of local arrangements and written clinical protocols
to ensure that people with small-cell lung cancer have treatment initiated
within 2 weeks of the pathological diagnosis.
Process: Proportion of people with small-cell lung cancer who have
treatment initiated within 2 weeks of the pathological diagnosis.
Quality statement 14: Optimal
follow-up regime
People with lung cancer are offered a specialist follow-up
appointment within 6 weeks of completing initial treatment
and regular specialist follow-up thereafter, which can
include protocol-led clinical nurse specialist follow-up.
Quality measure
Structure: Evidence of local arrangements and written clinical protocols
to ensure that people with lung cancer are offered a specialist follow-up
appointment within 6 weeks of completing initial treatment and regular
specialist follow-up thereafter, which can include protocol-led clinical
nurse specialist follow-up.
Process:
a) Proportion of people with lung cancer who receive a specialist followup appointment within 6 weeks of completing initial treatment.
b) Proportion of people with lung cancer who receive regular specialist
or protocol-led clinical nurse specialist follow-up after completing
initial treatment.
Quality statement 15:
Palliative interventions
People with lung cancer have access to all appropriate
palliative interventions delivered by expert clinicians and
teams.
Quality measure
Structure: Evidence of local arrangements and written clinical protocols
to ensure that people with lung cancer have access to all appropriate
palliative interventions delivered by expert clinicians and teams.
Process:
a) Proportion of people with lung cancer and bronchial obstruction who
receive endobronchial treatments.
b) Proportion of people with lung cancer and pleural effusion who
receive pleural aspiration or drainage.
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