| 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.Literature
searches completed 17.9.98
Top |
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)
Literature searches completed 17.9.98
Top |
| 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)Literature
searches completed 17.9.98
Top |
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)Literature searches completed 17.9.98
Top |
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) |
Literature
searches completed 17.9.98
Top
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)Literature searches completed 17.9.98
Top |
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) |
Literature searches
completed 17.9.98
Top
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)Literature searches completed 17.9.98
Top |
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) |
Literature
searches completed 17.9.98
Top
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) |
