CANCERS

Health Evidence Bulletins - Wales
Team Leader: Dr. Gordon Avery

Date of Completion: 17.09.98

1. LUNG CANCER

Lung Cancer is the most common cancer experienced by males in the United Kingdom. In the 5 year period 1986-1990 there were an average of 1,606 new registrations per annum for lung cancer in men in Wales.1
The annual average registration rate for 1984-1988 was 121.2 per 100,000, this being the highest registration rate for any of the regions in England and Wales.2 Registrations have been rising for many years but there are signs that a peak has now been reached.
The average annual number of deaths from lung cancer in males in Wales during the 5 year period 1992-1996 was 1284 and the annual average age standardised death rate for the same period was 74.2 per 100,000.3 The death rate in Wales is amongst the highest in the United Kingdom but it is now beginning to fall. The 5 year survival rate for lung cancer in men in Wales was less than 10% for cancers diagnosed between 1984 and 1988. 2
Lung cancer in women is on the increase. It is the second most common cancer (after breast) experienced by women. In the 5 year period 1986-1990 1 there was an average of 681 new registrations per annum for lung cancer in women in Wales.1
The average Annual Registration Rate for 1984-1988 was 44.6 per 100,000, this being amongst the highest for the regions of England and Wales.2 Registrations of lung cancer in women in Wales have been rising steadily in recent years. The average annual number of deaths from lung cancer in women in Wales during the 5 year period 1992-1996 was 636 and the average annual age standardised death rate for the same period was 28.2 per 100,000.
The death rate in Wales is among the highest in the UK and is steadily rising. The 5 year survival rate for lung cancer in women in Wales was less than 10% for cancers diagnosed between 1984 and 1988. 2
Lung cancer has not yet overtaken breast cancer as the most common cause of cancer deaths in women in Wales but this is likely to happen sometime early into the next century. The overall trends in lung cancer registrations and deaths in both men and women reflect the smoking patterns of at least 2-3 decades before the onset of the disease.

  1. Welsh Cancer Intelligence & Surveillance Unit: Cancer Registrations in Wales 1974-1990. Cardiff. WCISU. 1998.
  2. Welsh Health Common Services Authority. Cancer Registrations in Wales 1984-1988. Cardiff. Welsh Office. 1994.
  3. Welsh Health Common Services Authority. Health Show. Welsh Public Health Common Data Set. Cardiff. WHCSA. 1997.

A source document for several statements in this chapter (National Cancer Guidance Group. Guidance Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997) is summarised in an Effective Health Care bulletin (NHS Centre for Reviews and Dissemination, University of York.The management of lung cancer. Effective Health Care. 1998; 4(3))
http://www.york.ac.uk/inst/crd/ehc43.htm

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This document is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation
The Statements The Evidence
1.1 RISK FACTORS AND PREVENTION
1.1a. Smoking is responsible for more than 80% of all lung cancer cases. A lifetime smoker has a 20-30 times greater risk of developing lung cancer than a non-smoker. i,ii The risk of lung cancer increases directly with the number of cigarettes smoked. iii
( Health gain notation -6 "likely to be harmful")
i. Doll R, Peto R. The Cause of Cancer. Oxford: Oxford University Press, 1981
(Type V evidence - influential reports and studies)
ii. Peto R, Lopez AD, Boreham J, Thun M, Heath Jr C. Mortality from Smoking in Developed Countries 1950- 2000. Indirect Estimates from National Vital Statistics. Oxford: Oxford University Press, 1994
(Type IV evidence - well designed observational studies)
iii. Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years’ observations on male British doctors. British Medical Journal 1994; 309:910-11 http://www.bmj.com/cgi/content/abstract/309/6959/901
(Type IV evidence - prospective study)
1.1b. Individuals exposed to environmental tobacco smoke (ETS) over long periods of time (through passive smoking) experience an excess risk of 10-30% of developing lung cancer. This means an additional 2-3 lung cancer cases a year per 100,000 non-smokers regularly exposed to ETS. i
( Health gain notation -6 "likely to be harmful" )
i. Department of Health. Report of the Scientific Committee on Tobacco and Health. London: The Stationery Office, 1998
(Type IV evidence - observational studies)
1.1c. All people, particularly young people, should be encouraged not to start to smoke. i
(Health gain notation -1 "beneficial")
i. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type IV evidence - observational studies)
1.1d. Help should be given to those wishing to stop smoking. i
( Health gain notation -2 "likely to be beneficial")
See the Healthy Living bulletin in this series for the effectiveness of smoking cessation programmes. ii
i. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type I evidence - systematic review)
ii. In preparation.

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1.1e. Non- smokers should be protected from the effects of passive smoking.i
( Health gain notation -2 "likely to be beneficial")
See the Healthy Environments bulletin in this series for the health effects of passive smoking.ii
i. Office of Health & Environmental Assessment, Office of Research & Development, Washington DC: US Environmental Protection Agency. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. 1992
(Type IV evidence - observational studies)
ii. Health Evidence Bulletins – Wales: Healthy Environments. Cardiff: Welsh Office, 1999
http://hebw.cardiff.ac.uk
1.1f. A diet high in fruit and vegetables (especially green vegetables and carrots) protects against lung cancer.
(Health gain notation -2 "likely to be beneficial")
Low dietary levels of vitamin A and beta-carotene are associated with increased levels of lung cancer.i However intervention trials have found increases in lung cancer incidence and mortality in smokers who take beta-carotene supplements.ii
caveat: a high intake of these food constituents does not necessarily protect against lung cancer in the presence of heavy smoking levels.
i. World Cancer Research Fund in Association with American Institute for Cancer Research. Food, Nutrition and the Prevention of Cancer: a Global Perspective. Washington DC: AICR, 1997
(Type V evidence-expert opinion)
ii. Omenn GS, Goodman GE, Thornquist MF, et al. Risk factors for lung cancer and for intervention effects in CARET, the beta-Carotene And Retinol Efficacy Trial.
Journal of National Cancer Institute 1996; 88: 1550-9
(Type II evidence- randomised trial of 14254 smokers and 4060 asbestos-exposed male workers)
1.1g. A number of environmental exposures increase the risk of developing lung cancer. The agents involved include asbestos, radon (especially in miners), chromium, nickel and diesel exhaust.i
( Health gain notation -6 "likely to be harmful")
caveat: the effects of some of these exposures appear to be more manifest when combined with smoking.
i. World Cancer Research Fund in Association with American Institute for Cancer Research. Food, Nutrition and the Prevention of Cancer: a Global Perspective. Washington DC: AIRC, 1997
(Type V evidence-expert opinion)

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1.2 SCREENING
1.2a. Screening for lung cancer has been shown to be ineffective in reducing the mortality rate.i
(Health gain notation -5 "unlikely to be beneficial")
i. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type I evidence - systematic review)
ii. Fontana RS, Sanderson DR, Wodner LB et al. Lung cancer screening the major program. Journal of Occupational Medicine 1996; 28: 746-50
(Type V evidence - expert opinion)
1.3 DIAGNOSIS  
1.3a. Lung cancer should be suspected in any smoker with new or worsening respiratory symptoms including haemoptysis, or indication of systemic illness such as loss of energy, appetite, or weight. i
(Health gain notation -2 "likely to be beneficial")
i. Scottish Intercollegiate Guidelines Network. Management of Lung Cancer. Pilot edition. Edinburgh: SIGN, February 1998
http://www.sign.ac.uk
(Type V evidence – expert opinion and accepted good practice)
1.3b. Any patient with unexplained or persistent chest symptoms should have a chest x-ray even if the physical examination is normal.i Most symptomatic tumours can be seen on x-rays. ii
(Health gain notation -2 "likely to be beneficial")
i. Scottish Intercollegiate Guidelines Network. Management of Lung Cancer. Pilot edition. Edinburgh: SIGN, February 1998
http://www.sign.ac.uk
(Type V evidence – expert opinion and accepted good practice)
ii. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type IV evidence - observational studies)

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1.3c. Patients with a putative diagnosis of lung cancer should be referred for a specialist opinion at an early stage to identify those for whom curative treatment is appropriate. i,ii Surveys show that minimising the delay between the suspicion of cancer and the beginning of treatment is important to patients. ii
(Health gain notation -2 "likely to be beneficial" )
i. Muers MF, Higgins BG, Johnston IDA, Rudolf M, Pearce SJ, Pickles H: Lung Cancer Working Party of The British Thoracic Society Standards of Care Committee. BTS recommendations to respiratory physicians for organising the care of patients with lung cancer. Thorax 1998; 53 (Suppl1): S1-8
(Type IV evidence - observational studies)
ii. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type IV evidence - observational studies)
1.3d. Histological confirmation of the tumour is usually achieved using bronchoscopy although this can have adverse effects (mortality rate, 0.2%) and can be unpleasant for patients. There appears to be an association between higher histological diagnosis rates and improved survival rates. i,ii
(Health gain notation -3 "trade-off between beneficial and adverse effects" )
i. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type IV evidence-observational studies)
ii. Scottish Intercollegiate Guidelines Network. Management of Lung Cancer. Pilot edition. Edinburgh: SIGN, February 1998
http://www.sign.ac.uk
(Type IV evidence-observational studies)
1.3e. Radical treatment which may substantially increase life-expectancy is likely to be appropriate only for early-stage tumours. In non small cell lung cancer, accurate staging is particularly important for decision making about surgery.i The International System for Staging Lung Cancer has recently been revised.ii
(Health gain notation -2 "likely to be beneficial")
i. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type IV evidence - observational studies)
ii. Mountain CF. Revisions in the International System for Staging Lung Cancer. Chest 1997; 111(6): 1710-1717
(Type V evidence-expert opinion)
1.3f. A meta-analysis of 25 published studies shows that metastatic lung cancer (non small cell and small cell) can be reliably detected by careful clinical examination using predefined criteria and blood tests. In the absence of clinical suspicion of metastases or abnormal serum biochemistry, the chance of finding unsuspected metastases by routine organ scanning (of bones, liver and brain) is less than 5%.i
(Health gain notation - 2 "likely to be beneficial")
i. Silvestri GA, Littenberg B, Colice GL. The clinical evaluation for detecting metastatic lung cancer. A meta-analysis. American Journal of Respiratory and Critical Care Medicine 1995; 152: 225-230
http://ajrccm.atsjournals.org
(Type IV evidence - meta-analysis of observational studies)

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1.3g. In non-small cell tumours CT scanning is currently the optimal method of imaging the primary tumour and mediastinal lymph nodes for staging purpose. i
(Health gain notation - 2 "likely to be beneficial")
i. Quint LE, Francis IR, Wahl RL, Gross BH, Glazer GM. Preoperative staging of non-small-cell carcinoma of the lung: imaging methods. American Journal of Roentgenology 1995; 164: 1349-1359
http://www.ajronline.org/
(Type V evidence-expert opinion)
1.3h. Almost all patients with lung cancer want accurate information about diagnosis and treatment. Such information reduces anxiety even when the news is bad. i,ii,iii
(Health gain notation - 2 "likely to be beneficial")
i. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type IV evidence - observational studies)
ii. Scottish Intercollegiate Guidelines Network. Management of Lung Cancer. Pilot edition. Edinburgh: SIGN, February 1998
http://www.sign.ac.uk
(Type IV evidence-observational studies)
iii. Royal College of Radiologists Clinical Oncology Information Network. Guidelines for the non-surgical management of lung cancer. (now published) Clinical Oncology 1999; 11(1): Version 1
(Type IV evidence-observational studies)

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1.4 TREATMENT

1.4.1. Non-small Cell Lung Cancer (NSCLC)
1.4.1a. Surgery is the treatment of choice for anatomically localised tumours confirmed as NSCLC in patients fit enough to undergo thorocotomy and lung resection. i,ii However there is very little good quality evidence evaluating the effectiveness of surgery in NSCLC. i It is important to identify patients eligible for surgery without delay. iii
(Health gain notation-3 " trade-off between beneficial and adverse effects" )
i. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type I evidence – systematic review)
ii. Scottish Intercollegiate Guidelines Network. Management of Lung Cancer. Pilot edition. Edinburgh: SIGN, February 1998
http://www.sign.ac.uk
(Type I evidence – systematic review)
iii. Reviewers comments (see inside front cover)
1.4.1b. Radical radiotherapy should be considered in patients with otherwise operable disease who are medically unsuitable or who refuse surgery and in some patients whose local tumour is too extensive for surgery. i,ii Guidelines for best practice are in preparation. ii
Radical radiotherapy is probably under-used in the UK. iii
(Health gain notation -3 "trade-off between beneficial and adverse effects")
i. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type I evidence - systematic review)
ii. Royal College of Radiologists Clinical Oncology Information Network. Guidelines for the non-surgical management of lung cancer. (now published) Clinical Oncology 1999; 11(1): Version 1
(Type V evidence – expert opinion)
iii. Reviewers comments (see inside front cover)
1.4.1c. Continuous hyperfractionated accelerated radiotherapy (CHART) may be considered in the above patients.i In one study two year survival was 29% compared with 20% in those treated with conventional radiotherapy.ii
caveat: CHART is not available in Wales at the present time but is being actively considered in some centres. It is available at a few English centres, in one as part of a research trial.
(Health gain notation -2"likely to be beneficial")
i. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type I evidence - systematic review)
ii. Saunders M, Disch S, Barrett A et al. on behalf of the CHART Steering Committee. Continuous hyperfractionated accelerated radiotherapy (CHART) versus conventional radiotherapy in non-small cell lung cancer: a randomised multicentre trial. Lancet 1997; 350:161-65
(Type II evidence- randomised prospective trial of 563 patients)
1.4.1d. A meta-analysis showed that cisplatin-based chemotherapy in combination with surgery or radical radiotherapy, in advanced disease, leads to small and consistent improvements in survival compared with no chemotherapy. i
(Health gain notation -3 "trade-off between beneficial and adverse effects")
i. Non-small Cell Collaborative Group. Chemotherapy in non-small cell lung cancer: a meta-analysis using updated data on individual patients from 52 randomised clinical trials. British Medical Journal 1995, 311: 899-909
http://www.bmj.com/cgi/content/full/311/7010/899
(Type I evidence - systematic review of 9387 patients in 52 trials)

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1.4.1e. Patients in whom chemotherapy is considered should be treated within the context of controlled research protocols. i,ii Current large prospective studies including the Big Lung Trial should clarify the role of chemotherapy. iii
(Health gain notation -3 "trade-off between beneficial and adverse effects")
caveat: Future randomised controlled trials should include quality of life measurement in addition to survival .
i. Royal College of Radiologists Clinical Oncology Information Network. Guidelines for the non-surgical management of lung cancer. (now published) Clinical Oncology 1999; 11(1): Version 1
(Type V evidence-expert opinion)
ii. Scottish Intercollegiate Guidelines Network. Management of Lung Cancer. Pilot edition. Edinburgh: SIGN, February 1998
http://www.sign.ac.uk
(Type V evidence-expert opinion)
iii. Big Lung Trial. BLT: The Big Lung Trial. Does short-term chemotherapy improve the survival of patients with non-small cell lung cancer? A major randomised trial to determine the value of cisplatin-based chemotherapy for all patients with non-small cell lung cancer. UK, Protocol, Medical Research Council, 1997
(Type II evidence - randomised controlled trial in progress)
1.4.1f. Adjuvant radiotherapy, given before or after surgery, has not been shown to improve outcomes. A review of randomised trials has shown that postoperative radiotherapy may have a significant adverse effect on survival. The role of postoperative radiotherapy in the treatment of N2 tumours is not clear and further research may be needed.i
(Health gain notation -5 "unlikely to be beneficial")
i. PORT Meta-analysis Trialists Group. Postoperative radiotherapy in non-small-cell lung cancer: systematic review and meta-analysis of individual patient data from nine randomised controlled trials. Lancet 1998; 352: 257-263
(Type I evidence - systematic review of 9 randomised trials with 2128 patients)

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1.4.2 Small Cell Lung Cancer

1.4.2a. Combination chemotherapy is the treatment of choice for most patients with small cell lung cancer leading to better survival than with single agent treatment. A population based study between 1979 and 1986 showed a significant improvement in 2-year survival closely related to the use of intravenous combination chemotherapy. (from 2.5% to 7.5%). i In selected subgroups of patients survival as high as 30% at two years has been reported. ii
(Health gain notation -3"trade-off between beneficial and adverse effects")
i. Watkin SW, Hayhurst GK, Green JA. Time trends in the outcome of lung cancer management: a study of 9,090 cases diagnosed in the Mersey region. 1974-1986. British Journal of Cancer 1996; 61: 590-596
(Type IV evidence - observational study)
ii. Royal College of Radiologists Clinical Oncology Information Network. Guidelines for the non-surgical management of lung cancer. (now published) Clinical Oncology 1999; 11(1): Version 1
(Type IV evidence - observational study. Described in Thatcher N. Ifosfamide, carboplatin, etoposide (ICE) regimen in small cell lung cancer. Lung Cancer 1993; 9(Suppl 1): 51-67)
1.4.2b. Two trials in the early 1990s suggested that single agent chemotherapy may be an appropriate treatment for patients with small cell lung cancer and poor performance status (elderly or less well).i However a recent randomised controlled trial showed that combination chemotherapy is more effective and less toxic. ii
(Health gain notation - 6 "likely to be ineffective or harmful")
i. DeVita.VT, Hellman S, Rosenberg SA (eds.) Cancer: Principles and Practice of Oncology. 5th ed. Philadelphia: Lippincott-Raven, 1997 p.922
(Type II evidence – expert summary citing the results of two randomised controlled trials)
ii. Medical Research Council Lung Cancer Working Party. Comparison of oral etoposide and standard intravenous multidrug chemotherapy for small cell lung cancer: A stopped multicentre randomised trial. Lancet 1996; 348: 563-566
(Type II evidence – randomised controlled trial of 339 patients)
1.4.2c. A meta-analysis of 30 randomised controlled trials show that 5-HT3 receptor antogonists are significantly more effective than conventional anti-emetics for prophylaxis of acute vomiting caused by cytotoxic chemotherapy, whether or not this includes particularly emetogenic drugs such as cisplatin.
In 15 trials with cisplatin treatments, odds ratio, OR=0.60 (95% CI, 0.51-0.70) and in 11 trials with moderately emetogenic treatments, OR=0.47 (95% CI, 0.39-0.58).i
(Health gain notation - 2 "likely to be beneficial")
i. Jantunen IT, Kataja VV, Muhonen TT. An overview of randomised studies comparing 5-HT3 receptor antagonists to conventional anti-emetics in the prophylaxis of acute chemotherapy induced vomiting. European Journal of Cancer 1997; 33: 66-74
(Type I evidence - meta-analysis of 30 randomised controlled trials)

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1.4.2d. One randomised controlled trial showed that the addition of surgery to chemotherapy did not improve outcomes. i
(Health gain notation - 6 "likely to be ineffective or harmful)
i. Lad T, Piantadosi S, Thomas P et al. A prospective randomised trial to determine the benefit of surgical resection of residual disease following response of small cell lung cancer to combination chemotherapy. Chest 1994; 106: 320S-323S
(Type II evidence - prospective randomised controlled trial of 146 patients)
1.4.2e. Thoracic Radiotherapy to the primary site reduces local recurrence rates and significantly improves overall survival in those with limited disease who are also treated with chemotherapy. i,ii A meta-analysis showed a 5.4% improvement in three year survival.i The timing of thoracic radiotherapy is controversial. iii
(Health gain notation - 2 "likely to be beneficial")
Caveat : Further research is recommended to optimise regimes
i. Pignon JP, Arriagada R, Ihde DC et al. A Meta-analysis of thoracic radiotherapy for small cell lung cancer. New England Journal of Medicine 1992; 327 (23): 1618-24
(Type I evidence - systematic review of 13 randomised trials with 2103 patients with limited disease)
ii. Warde P, Payne D. Does thoracic irradiation improve survival and local control in limited-stage small-cell carcinoma of the lung? A meta-analysis. Journal of Clinical Oncology 1992; 10: 890-895
(Type I evidence - meta-analysis of 11 randomised trials)
iii. Royal College of Radiologists Clinical Oncology Information Network. Guidelines for the non-surgical management of lung cancer. (now published) Clinical Oncology 1999; 11(1): Version 1
(Type II evidence - randomised controlled trials)
1.4.2f. Prophylactic cranial irradiation (PCI) can significantly enhance survival and reduce the risk of brain metastases without compromising quality of life in patients in complete remission following chemotherapy. i,ii
(Health gain notation - 2 "likely to be beneficial")
i. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type II evidence - randomised trial. Described in
Gregor A, Cull A,Stephens RJ, et al. Prophylactic cranial irradiation is indicated following complete response to induction therapy in small cell lung cancer: Results of a multicentre randomised trial. European Journal of Cancer 1997; 33:1752-8)
ii. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type I evidence-meta-analysis. Described in Arrigada R, Auperin A, Pignon JP, et al. Prophylactic cranial irradiation overview (PICO) in patients with small cell ling cancer (SCLC) in complete remission (CR). Proceedings of the American Society of Clinical Oncology 1998;17: 457a)

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1.5 FOLLOW UP AND CONTINUING CARE

1.5a. Palliative surgery does not offer significant potential for improvements in quality of life. i
(Health gain notation - 6 "likely to be ineffective or harmful")
i. Standing Medical Advisory Committee. Management of Lung Cancer: Current Clinical Practices. London: SMAC, 1994
(Type V evidence - expert opinion)
1.5b. Palliative radiotherapy may be used to treat symptoms resulting from locally advanced or metastatic disease and guidelines for best practice are available. i,ii
(Health gain notation - 2 "likely to be beneficial")
i. Scottish Intercollegiate Guidelines Network. The Use of Palliative Radiotherapy in the Treatment of Non Small Cell Lung Cancer. Pilot edition. Edinburgh: SIGN, March 1996
(Review of effective procedures classified according to the type of evidence)
http://www.sign.ac.uk
ii. Royal College of Radiologists Clinical Oncology Information Network. Guidelines for the non-surgical management of lung cancer. (now published) Clinical Oncology 1999; 11(1): Version 1
(Type II evidence - randomised trials)
1.5c. When breathlessness is cause by obstruction of main airways it is normally treated with external beam radiotherapy. If this is not possible, itraluminal brachytherapy (IBT) can be used but this carries a risk of serious adverse effects, including fatal haemoptysis in perhaps 20% of patients. i
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
caveat Other methods of opening the airways include laser treatment, cryotherapy and stent insertion. All have been reported to produce rapid improvements but there have been no comparative trials.
i. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type I evidence - systematic review)
1.5d. Specialist Nurses can have an important role in the support of patients with lung cancer. Counselling and breathing retraining can reduce anxiety and enhance patients’ ability to cope with the effects of breathlessness. i A multicentre randomised trial showed that patients who attended a nursing clinic offering an intervention for their breathlessness experienced improvements in their breathlessness and performance status.ii
(Health gain notation - 2 "likely to be beneficial")
i. National Cancer Guidance Group. Improving Outcomes in Lung Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1998
(Type I evidence - systematic review)
ii. Multicentre randomised controlled trial of nursing intervention for breathlessness in patients with lung cancer. (now published) British Medical Journal 1999; 318 : 901-904
(Type II evidence- randomised controlled study of 119 patients)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk