Lung cancer: diagnosis and management: summary of updated NICE guidance
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l1049 (Published 28 March 2019) Cite this as: BMJ 2019;364:l1049- 1National Institute for Health and Care Excellence, London, UK
- 2Lungs for Living Research Centre, UCL Respiratory, University College London; and Department of Thoracic Medicine, University College London Hospital, London, UK
- 3Queen's University Belfast; and Belfast Health and Social Care Trust, Belfast, UK
- Correspondence to: R Maconachie ross.maconachie{at}nice.org.uk
What you need to know
The NICE guideline for lung cancer focuses on diagnosis and treatment, it does not cover referral for suspected cancer
The guidance has been updated, and the new recommendations are largely relevant to secondary care settings, but some updates may be useful for non-specialists to be aware of
A new staging algorithm for non-small cell lung cancer describes when to use several diagnostic and staging investigations and in what order
A new systemic therapy algorithm recommends medications for advanced non-small cell lung cancer based on patient tumour histology and biomarkers and will be periodically updated as new developments occur
People with stage II and III non-small cell lung cancer being considered for curative treatment should receive brain imaging prior to treatment as the presence of brain metastases alters their management plan.
What this guideline update covers
This National Institute for Health and Care Excellence (NICE) guideline update covers the diagnosis and treatment of lung cancer.1 Recommendations on referral for suspected cancer are covered in a separate guideline.2
Why did it need updating?
New trials and systematic reviews have been published in several relevant areas since the 2011 update of this guideline, particularly in the areas of staging, radiotherapy, and systemic treatments.
Who is it for?
The new recommendations are largely focused on secondary care, but the guideline is relevant to all stakeholders with an interest in the diagnosis and management of patients with lung cancer, including those in primary care.
What evidence was reviewed?
Evidence was reviewed on the use of:
Non-ultrasound-guided transbronchial needle aspiration, endobronchial ultrasound-guided transbronchial needle aspiration, and endoscopic ultrasound-guided fine-needle aspiration for diagnosis
Use of magnetic resonance imaging (MRI) or computed tomography (CT) of the brain before treatment with curative intent
Treatments for operable stage IIIA-N2 non-small cell lung cancer (NSCLC)
Radiotherapy regimens with curative intent for NSCLC
Chemoradiotherapy for people with limited-stage small cell lung cancer (SCLC)
Thoracic radiotherapy for people with extensive-stage SCLC
Prophylactic cranial irradiation in people with extensive-stage SCLC.
The guideline includes:
A new algorithm for the nodal staging of NSCLC (fig 1)
Diagrams that present and sequence the large number of systemic therapy options that are available to people with advanced disease.
Lung cancer facts
Lung cancer is the commonest cause of cancer death in the UK and worldwide, with an annual incidence of 35 000 and 1.7 million respectively. The two main types of lung cancer are non-small cell and small cell lung cancer
Lung cancer is currently classified using the TNM-8 system, in which the size of the primary tumour, the extent of lymph node involvement within the thorax, and the presence of extra-thoracic metastases are used to classify patients into stages
Patients with stage I or II non-small cell lung cancer (NSCLC) are offered surgery, which may be followed by adjuvant treatment depending upon the pathological staging. Those not undergoing surgery due to patient physiology or preferences are offered radical radiotherapy
Treatment for stage III NSCLC is complex but often includes chemoradiation or surgery followed by adjuvant treatments or chemoradiation followed by surgery
Systemic treatment of patients with stage IV NSCLC is guided by histology and predictive biomarkers
People with small cell lung cancer are typically treated with chemotherapy and/or radiotherapy, with surgery being offered for selected early tumours
What are the key new recommendations?
Diagnosis and staging
After initial imaging with CT, many patients with a working diagnosis of lung cancer will require further investigation to clarify the stage of the disease and determine what treatment options are best for them.
The guideline clarifies when to use positron emission tomography (PET)-CT, endobronchial ultrasound-guided transbronchial needle aspiration, endoscopic ultrasound fine needle aspiration, and surgical staging (see fig 1).
The guideline no longer recommends using non-ultrasound-guided transbronchial needle aspiration.
The guideline recommends that people with stage II or III non-small cell lung cancer being considered for curative treatment should receive brain imaging before treatment because the presence of brain metastases may alter their management plan.
Treatment of stage I–III non-small cell lung cancer
Overall, lobectomy remains the treatment of choice for stage I and II non-small cell lung cancer.
For patients not undergoing surgical resection, the guidance now recommends stereotactic ablative radiotherapy (SABR), a newer radiotherapy technique as a treatment option for primary lung tumours ≤5 cm in diameter without evidence of metastatic spread. SABR uses multiple small beams of radiation with high precision, limiting damage to normal tissue. A complete course of SABR can be delivered with fewer visits compared with conventional fractionation schedules. However, SABR is not indicated in all patients, for example, in patients whose tumours are within a 2 cm radius of the main airways and proximal bronchial tree.
For patients not undergoing surgical resection or SABR, the guideline recommends conventional or hyperfractionated radiotherapy schedules and does not distinguish between the different schedules.
Centres with suitable expertise should now consider offering chemoradiotherapy and surgery to patients with operable stage IIIA-N2 non-small cell lung cancer, a patient group for whom the optimal management strategy has been extensively debated in the literature. The recommendations were informed by a new meta-analysis suggesting improved progression-free survival with chemoradiotherapy and surgery.
Systemic treatment of advanced non-small cell lung cancer
A large number of new drugs for the systemic treatment of advanced (stage IIIB and IV) non-small cell lung cancer have been developed in the past decade. Many of these have undergone independent technology appraisals by NICE advisory committees.
The guideline includes new systemic medication algorithms based on patient tumour histology and biomarkers (squamous3 and non-squamous4 non-small cell lung cancer.
Innovations in this area are frequent, and the pathway will be updated periodically on the NICE website.
Treatment for small cell lung cancer
Chemotherapy remains the mainstay of treatment for patients with small cell lung cancer. Brain metastases are common, and it was previously recommended to offer whole brain radiotherapy prophylactically to patients without brain metastases who respond to first line chemotherapy. Evidence published since the previous guideline reduces confidence in the survival benefits associated with this strategy in people with advanced disease.
The recommendation for prophylactic cranial irradiation in patients with small cell lung cancer was downgraded from “offer” to “consider,” meaning that it is now a weaker recommendation.
In addition, clinicians should consider thoracic radiotherapy in patients who respond to chemotherapy and receive prophylactic cranial irradiation.
Centres should now offer twice-daily chemoradiotherapy for patients with limited-stage small cell lung cancer rather than once daily if possible.
How patients were involved in the creation of this article
The guideline committee included three lay members; one with experience as a lung cancer patient, one with experience as a carer of a patient with lung cancer, and an employee from a lung cancer charity. We thank them for sharing their experiences and expertise and helping to ensure that the guideline took account of the perspective of lung cancer patients and their families and carers.
Acknowledgments
Members of the Guideline Committee were Gary McVeigh (chair), Neal Navani, Douglas West, Shahzeena Aslam, Lynn Campbell, Rhiannon Walters-Davies, Andrea McIver, Elaine Borg, Sujal Desai, Steve Connor, Clifford Jones, Jesme Fox, Tom Haswell, and Nigel Westwood
Footnotes
Contributors: RM drafted this article, which was edited and commented on by the other contributors.
Competing interests: NN and GM were members of the NICE Guideline Committee. The committee’s declarations of interest are available on the NICE website (https://www.nice.org.uk/guidance/NG122/history). RM and TM are NICE staff and have no relevant interests to declare.