NICE肺癌诊断和管理指南（2019）

Lung cancer: diagnosis and management
NICE guideline
Published: 28 March 2019

1.1 Access to services and referralThe importance of early diagnosis

1.1.1The public needs to be better informed of the symptoms and signs that are characteristic of lung cancer, through coordinated campaigning to raise awareness. [2005]

Referral and indications for chest radiography

1.1.2For guidance on referral, see the recommendations on referral for suspected lung cancer in the NICE guideline on suspected cancer. [2019]

1.2 Communication

1.2.1Find 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. [2011]

1.2.2Ensure 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. [2011]

1.2.3Offer 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. [2011]

1.2.4Consider 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. [2011]
  
  

1.2.5Offer 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. [2011]

1.2.6Respect the person's choice if they do not wish to confront future issues. [2011]

1.2.7Avoid giving people unexpected bad news in writing. Only give unexpected bad news by phone in exceptional circumstances. [2011]

1.2.8Offer 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. [2011]

1.2.9Document 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. [2011]
  
  

1.2.10Share 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. [2011]
  
  

1.3 Diagnosis and stagingEffectiveness of diagnostic and staging investigations

1.3.1Only 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. [2005]

1.3.2Offer people with known or suspected lung cancer a contrast-enhanced chest 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. [2005, amended 2019]

1.3.3When 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. [2005]
  
  

1.3.4Ensure that all people with lung cancer who could potentially have treatment with curative intent are offered positron-emission tomography CT (PET‑CT) before treatment. [2011]

1.3.5Every cancer alliance should have a system of rapid access to PET‑CT scanning for eligible people. [2005, amended 2019]

1.3.6Do not routinely use MRI to assess the stage of the primary tumour (T‑stage) in non-small-cell lung cancer (NSCLC). [2005]

1.3.7Use MRI when necessary to assess the extent of disease, for people with superior sulcus tumours. [2005]

1.3.8Offer endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for biopsy of paratracheal and peri-bronchial intra-parenchymal lung lesions. [2011]

1.3.9Every cancer alliance should have at least 1 centre with EBUS and/or endoscopic ultrasound (EUS) to ensure timely access. [2011]

1.3.10Audit the local test performance of EBUS-TBNA and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). [2011, amended 2019]

1.3.11When taking samples, ensure they are adequate (without unacceptable risk to the person) to permit pathological diagnosis, including tumour subtyping and assessment of predictive markers. [2011, amended 2019]

1.3.12For guidance on 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. [2019]

For a short explanation of why the committee made the 2019 recommendation and how it might affect practice, see the rationale and impact section on effectiveness of diagnostic and staging investigations.

Full details of the evidence and the committee's discussion are in evidence review A: Investigations for staging the mediastinum.

Sequence of investigations

1.3.13Choose 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. [2011]

1.3.14Perform contrast-enhanced CT of the chest, liver adrenals and lower neck before any biopsy procedure. [2005, amended 2019]

Peripheral primary tumour

1.3.15Offer image-guided biopsy to people with peripheral lung lesions when treatment can be planned on the basis of this test. [2011, amended 2019]

1.3.16Biopsy 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. [2011, amended 2019]

Central primary tumour

1.3.17Offer flexible bronchoscopy to people with central lesions on CT if nodal staging does not influence treatment. [2011, amended 2019]

Intrathoracic lymph node assessment

1.3.18Offer 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. [2011, amended 2019]

1.3.19Offer 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. [2019]

1.3.20Evaluate PET-CT-positive or enlarged intrathoracic nodes using a systematic approach (sampling any suspicious node on CT, PET or USS) with EBUS‑TBNA and/or EUS‑FNA if nodal status would affect the treatment plan. [2019]

1.3.21Consider 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. [2019]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on EBUS-TBNA and EUS-FNA.

Full details of the evidence and the committee's discussion are in evidence review A: Investigations for staging the mediastinum.

Further staging

1.3.22Confirm 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. [2011]

1.3.23Do not offer dedicated brain imaging to people with clinical stage I NSCLC who have no neurological symptoms and are having treatment with curative intent. [2019]

1.3.24Offer 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. [2019]

1.3.25Offer contrast-enhanced brain MRI for people with stage III NSCLC who are having treatment with curative intent. [2019]

1.3.26Offer people with clinical features suggestive of intracranial pathology CT of the head followed by MRI if normal, or MRI as an initial test. [2011]

1.3.27Perform 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. [2005]

1.3.28Avoid bone scintigraphy when PET-CT has not shown bone metastases. [2011]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on brain imaging for people having treatment with curative intent.

Full details of the evidence and the committee's discussion are in evidence review B: Brain imaging for people with NSCLC selected for treatment with curative intent.

Organisational factors relevant to diagnosis and staging

1.3.29Provide 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. [2005, amended 2019]

Multidisciplinary teams

1.3.30Refer all people with a suspected diagnosis of lung cancer to a member of a lung cancer multidisciplinary team (usually a chest physician). [2005]

1.3.31The care of all people with a working diagnosis of lung cancer should be discussed at a lung cancer multidisciplinary team meeting. [2005]

Fast track lung clinics

1.3.32Provide 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. [2005]

Cancer clinical nurse specialists

1.3.33All 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. [2005, amended 2019]
  
  

1.4 TreatmentStop smoking interventions and services

1.4.1Inform people that smoking increases the risk of pulmonary complications after lung cancer surgery. [2011]

1.4.2Advise people to stop smoking as soon as the diagnosis of lung cancer is suspected and tell them why this is important. [2011]

1.4.3Offer nicotine replacement therapy and other therapies to help people to stop smoking in line with the NICE guideline on stop smoking interventions and services and the NICE technology appraisal guidance on varenicline for smoking cessation. [2011]

1.4.4Do not postpone surgery for lung cancer to allow people to stop smoking. [2011]

Assessing people with non-small-cell lung cancer for treatment with curative intentPerioperative mortality

1.4.5When 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. [2011]

Cardiovascular function

1.4.6Avoid surgery within 30 days of myocardial infarction. [2011]

1.4.7Seek a cardiology review in people with an active cardiac condition, or 3 or more risk factors, or poor cardiac functional capacity. [2011]

1.4.8Offer surgery without further investigations to people with 2 or fewer risk factors and good cardiac functional capacity. [2011]

1.4.9Optimise any primary cardiac treatment and begin secondary prophylaxis for coronary disease as soon as possible. [2011]

1.4.10Continue anti-ischaemic treatment in the perioperative period, including aspirin, statins and beta-blockers. [2011]

1.4.11For people with coronary stents, discuss perioperative anti-platelet treatment with a cardiologist. [2011]

1.4.12Consider revascularisation (percutaneous intervention or coronary artery bypass grafting) before surgery for people with chronic stable angina and conventional indications for revascularisation. [2011]

Lung function

1.4.13Perform spirometry and transfer factor (TLCO) in all people being considered for treatment with curative intent. [2011, amended 2019]

1.4.14Offer people surgery if they have a forced expiratory volume in 1 second (FEV1) within normal limits and good exercise tolerance. [2011]

1.4.15When considering surgery perform a functional segment count to predict postoperative lung function. [2011]

1.4.16Offer 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. [2011, amended 2019]

1.4.17Consider 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. [2011]

1.4.18Consider 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. [2011]

Assessment before radiotherapy with curative intent

1.4.19A clinical oncologist specialising in thoracic oncology should determine suitability for radiotherapy with curative intent, taking into account performance status and comorbidities. [2011]

Surgery and radiotherapy with curative intent for non-small-cell lung cancerSurgery

1.4.20For people with NSCLC who are well enough and for whom treatment with curative intent is suitable, offer lobectomy (either open or thoracoscopic). [2019]

1.4.21Offer more extensive surgery (bronchoangioplastic surgery, bilobectomy, pneumonectomy) only when needed to obtain clear margins. [2011]

1.4.22Perform hilar and mediastinal lymph node sampling or en bloc resection for all people having surgery with curative intent. [2011]

1.4.23For 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. [2005]

Surgery or radiotherapy for people not having lobectomy

1.4.24For people with stage I–IIA (T1a–T2b, N0, M0) NSCLC who decline lobectomy or in whom it is contraindicated, offer radical radiotherapy with stereotactic ablative radiotherapy (SABR) or sublobar resection. [2019]

Radical radiotherapy for people not having surgery

1.4.25All people should have pulmonary function tests (including lung volumes and transfer factor) before radical radiotherapy for NSCLC. [2005]

1.4.26People receiving radiotherapy with curative intent should be part of a national quality assurance programme. [2011]

1.4.27For 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. [2019]

1.4.28For eligible people with stage IIIA NSCLC who cannot tolerate or who decline chemoradiotherapy (with or without surgery), consider radical radiotherapy (either conventional or hyperfractionated). [2019]

1.4.29For eligible people with stage IIIB NSCLC who cannot tolerate or who decline chemoradiotherapy, consider radical radiotherapy (either conventional or hyperfractionated). [2019]

Radiotherapy fractionation

1.4.30If using SABR, follow the SABR Consortium guidance on fractionation. [2019]

1.4.31If 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. [2019]
  
  

For a short explanation of why the committee made the 2019 recommendations, and how they might affect practice, see the rationale and impact section on surgery and radiotherapy with curative intent for non-small-cell lung cancer.

Full details of the evidence and the committee's discussion are in evidence review D: Radiotherapy with curative intent for NSCLC.

Combination treatment for non-small-cell lung cancer

1.4.32Consider 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. [2011]

1.4.33Ensure 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. [2011]

1.4.34Offer postoperative chemotherapy to people with good performance status (WHO 0 or 1) and T1a–4, N1–2, M0 NSCLC. [2011]

1.4.35Consider 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. [2011]

1.4.36Offer a cisplatin-based combination chemotherapy regimen for adjuvant chemotherapy. [2011]

1.4.37For people with stage I–II NSCLC that are suitable for surgery, do not offer neo-adjuvant treatment outside a clinical trial. [2011, amended 2019]

1.4.38Ensure eligible people have the benefit of detailed discussion of the risks and benefits of adjuvant chemotherapy. [2011]

1.4.39Treat 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. [2011]

1.4.40For people with operable stage IIIA–N2 NSCLC who can have surgery and are well enough for multimodality therapy, consider chemoradiotherapy with surgery. [2019]

1.4.41Discuss 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. [2019]
  
  

1.4.42For 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. [2019]

1.4.43Multidisciplinary teams that provide chemoradiotherapy with surgery should have expertise in the combined therapy and in all of the individual components. [2019]

1.4.44Centres performing lung resections for lung cancer should validate their data for the Lung Cancer Clinical Outcomes publication and the National Lung Cancer Audit. [2019]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on management of operable stage IIIA–N2 non-small-cell lung cancer.

Full details of the evidence and the committee's discussion are in evidence review C: Management of NSCLC stage IIIA-N2.

Systemic anti-cancer therapy (SACT) for advanced non-small-cell lung cancer

NICE has also produced visual summaries covering systemic treatment options for advanced NSCLC:

• for people with stage IIIB and IV non-squamous (adenocarcinoma, large cell undifferentiated) carcinoma and non-small-cell carcinoma (non-otherwise specified)
• for people with stage IIIB and IV squamous non-small-cell carcinoma.
  
  

Non-squamous non-small-cell lung cancer, stages IIIB and IV

EGFR-TK mutation

1.4.45For guidance on treatment for stage IIIB and IV non-squamous NSCLC in people with the epidermal growth factor receptor tyrosine kinase (EGFR-TK) mutation:

• for initial treatment, see the NICE technology appraisal guidance on afatinib, erlotinib and gefitinib.
• on progression for people with the EGFR T790M mutation, see the NICE technology appraisal guidance on osimertinib.
• on progression after afatinib, erlotinib, gefitinib or osimertinib, offer pemetrexed with carboplatin or other platinum doublet chemotherapy
• for disease that does not immediately progress after chemotherapy, see the NICE technology appraisal guidance on pemetrexed maintenance after pemetrexed and pemetrexed maintenance after other platinum doublet chemotherapy
• on progression after first-line chemotherapy, see the NICE technology appraisal guidance on atezolizumab, nivolumab, pembrolizumab and nintedanib with docetaxel or offer docetaxel monotherapy. [2019]
  
  In March 2019, this was an off-label use of some combinations of platinum doublet chemotherapy. See NICE's information on prescribing medicines.
  
  

ALK gene rearrangement

1.4.46For guidance on treatment for stage IIIB and IV non-squamous NSCLC in people with the anaplastic lymphoma kinase-positive gene rearrangement:

• for first-line systemic treatment, see the NICE technology appraisal guidance on crizotinib, ceritiniband alectinib
• on progression after first-line crizotinib, see the NICE technology appraisal guidance on ceritinib and brigatinib for second-line treatment
• on progression, offer pemetrexed with carboplatin or other platinum doublet chemotherapy
• for disease that does not immediately progress after chemotherapy, see the NICE technology appraisal guidance on pemetrexed maintenance after pemetrexed and pemetrexed maintenance after other platinum doublet chemotherapy
• on progression after first-line chemotherapy, see the NICE technology appraisal guidance on atezolizumab, nivolumab, pembrolizumab and nintedanib with docetaxel or offer docetaxel monotherapy. [2019]
  
  In March 2019, this was an off-label use of some combinations of platinum doublet chemotherapy. See NICE's information on prescribing medicines.
  
  

PDL1≥50% and no gene mutation or fusion protein

1.4.47For guidance on treatment for stage IIIB and IV non-squamous NSCLC in people whose tumours express PD-L1 at 50% or above and who have no gene mutation or fusion protein:

• for initial treatment, see the NICE technology appraisal guidance on pembrolizumab and pembrolizumab combination
• on progression after pembrolizumab, offer pemetrexed with carboplatin or other platinum doublet chemotherapy
• for disease that does not immediately progress after chemotherapy, see the NICE technology appraisal guidance on pemetrexed maintenance after pemetrexed and pemetrexed maintenance after other platinum doublet chemotherapy
• on progression after first-line chemotherapy or pembrolizumab combination, see the NICE technology appraisal guidance on nintedanib with docetaxel or offer docetaxel monotherapy. [2019]
  
  In March 2019, this was an off-label use of some combinations of platinum doublet chemotherapy. See NICE's information on prescribing medicines.
  
  

ROS1 positive

1.4.48For guidance on treatment for stage IIIB and IV ROS1-positive non-squamous NSCLC:

• for initial treatment, see the NICE technology appraisal guidance on crizotinib
• on progression offer pemetrexed with carboplatin or other platinum doublet chemotherapy
• for disease that does not immediately progress after chemotherapy, see the NICE technology appraisal guidance on pemetrexed maintenance after pemetrexed and pemetrexed maintenance after other platinum doublet chemotherapy
• on progression after first-line chemotherapy see the NICE technology appraisal guidance on atezolizumab, nivolumab, pembrolizumab and nintedanib with docetaxel or offer docetaxel monotherapy. [2019]
  
  In March 2019, this was an off-label use of some combinations of platinum doublet chemotherapy. See NICE's information on prescribing medicines.
  
  

No gene mutation or fusion protein and PD-L1<50%

1.4.49For guidance on treatment for stage IIIB and IV non-squamous NSCLC in people who do not have a gene mutation, fusion protein or biomarker:

• See the NICE technology appraisal guidance on pembrolizumab combination and pemetrexed with cisplatin or offer pemetrexed with carboplatin or other platinum doublet chemotherapy
• for disease that does not immediately progress after chemotherapy, see the NICE technology appraisal guidance on pemetrexed maintenance after pemetrexed and pemetrexed maintenance after other platinum doublet chemotherapy
• on progression after first-line chemotherapy see the NICE technology appraisal guidance on atezolizumab, nivolumab, pembrolizumab and nintedanib with docetaxel or offer docetaxel monotherapy
• on progression after pembrolizumab combination, see the NICE technology appraisal guidance on nintedanib with docetaxel or offer docetaxel monotherapy. [2019]
  
  In March 2019, this was an off-label use of some combinations of platinum doublet chemotherapy. See NICE's information on prescribing medicines.
  
  

Squamous non-small-cell lung cancer

PDL1≥50%

1.4.50For guidance on treatment for squamous NSCLC in people whose tumours express PD-L1 at or above 50%:

• for initial treatment, see the NICE technology appraisal guidance on pembrolizumab
• on progression, offer gemcitabine or vinorelbine and cisplatin or carboplatin
• on progression after first-line chemotherapy, offer docetaxel monotherapy. [2019]
  
  In March 2019, this was an off-label use gemcitabine with cisplatin. See NICE's information on prescribing medicines.
  
  

PDL1<50%

1.4.51For guidance on treatment for squamous NSCLC in people whose tumours express PD-L1 below 50%:

• for initial treatment, offer gemcitabine or vinorelbine and cisplatin or carboplatin
• on progression after first-line chemotherapy, see the NICE technology appraisal guidance on atezolizumab, nivolumab and pembrolizumab, or offer docetaxel monotherapy. [2019]
  
  In March 2019, this was an off-label use gemcitabine with cisplatin. See NICE's information on prescribing medicines.
  
  

Assessing people with small-cell lung cancer

1.4.52Arrange for people with small-cell lung cancer (SCLC) to have an assessment by a thoracic oncologist within 1 week of deciding to recommend treatment. [2011]

First-line treatment for limited-stage disease small-cell lung cancer

1.4.53Offer 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. [2011]

1.4.54Offer 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. [2019]

1.4.55If the person declines or is unable to have twice-daily radiotherapy, offer once-daily radiotherapy. [2019]

1.4.56Offer 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. [2019]

1.4.57Offer 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. [2011, amended 2019]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on first-line treatment for limited-stage disease SCLC.

Full details of the evidence and the committee's discussion are in evidence review F: Chemoradiotherapy for limited stage SCLC.

Surgery for small-cell lung cancer

1.4.58Consider surgery in people with early-stage SCLC (T1–2a, N0, M0). [2011]

First-line treatment for extensive-stage disease small-cell lung cancer

1.4.59Offer 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. [2011]

1.4.60Assess 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. [2011]

1.4.61Consider 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. [2019]

1.4.62Consider 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. [2019]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on thoracic radiotherapy and prophylactic cranial irradiation in SCLC.

Full details of the evidence and the committee's discussion are in evidence review G: Thoracic radiotherapy for extensive stage SCLC and evidence review H: Prophylactic cranial irradiation for extensive stage SCLC.

Maintenance treatment for small-cell lung cancer

1.4.63Only offer maintenance treatment to people with SCLC in the context of a clinical trial. [2011]

Second-line treatment for small-cell lung cancer that has relapsed after first-line treatment

1.4.64Offer people with SCLC that has relapsed after first-line treatment assessment by a thoracic oncologist. [2011]

1.4.65Inform people whose disease has not responded to first-line treatment that there is very limited evidence that second-line chemotherapy will be of benefit. [2011]

1.4.66Offer 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. [2011]

1.4.67Offer radiotherapy for palliation of local symptoms to people with SCLC that has relapsed after first-line treatment. [2011]

Topotecan

1.4.68Refer to the NICE technology appraisal guidance on topotecan for the treatment of relapsed small-cell lung cancer. [2009]

1.5 Palliative interventions and supportive and palliative careProviding palliative care

1.5.1Supportive and palliative care of the person should be provided by general and specialist palliative care providers in line with the NICE guidance on improving supportive and palliative care for adults with cancer. [2005]

1.5.2Identify and refer people who may benefit from specialist palliative care services without delay. [2005]

Palliative radiotherapy

1.5.3Provide palliative radiotherapy, either as symptoms arise or immediately, for eligible people who cannot be offered curative treatment. [2005]

Managing endobronchial obstruction

1.5.4When people have large airway involvement, monitor (clinically and radiologically) for endobronchial obstruction to ensure treatment is offered early. [2011]

1.5.5Offer external beam radiotherapy and/or endobronchial debulking or stenting to people with impending endobronchial obstruction. [2011]

1.5.6Every cancer alliance should ensure that people have rapid access to a team capable of providing interventional endobronchial treatments. [2011]

Other palliative treatments

1.5.7Perform pleural aspiration or drainage in an attempt to relieve the symptoms of a pleural effusion. [2005]

1.5.8Patients who benefit symptomatically from aspiration or drainage of fluid should be offered talc pleurodesis for longer-term benefit. [2005]

1.5.9Consider non-drug interventions based on psychosocial support, breathing control and coping strategies for people with breathlessness. [2005]

1.5.10Non-drug interventions for breathlessness should be delivered by a multidisciplinary group, coordinated by a professional with an interest in breathlessness and expertise in the techniques (for example, a nurse, physiotherapist or occupational therapist). Although this support may be provided in a breathlessness clinic, people should have access to it in all care settings. [2005]

1.5.11Consider opioids, such as codeine or morphine, to reduce cough. [2005]

1.5.12Refer people with troublesome hoarseness due to recurrent laryngeal nerve palsy to an ear, nose and throat specialist for advice. [2005]

1.5.13Offer people who present with superior vena cava obstruction chemotherapy and radiotherapy according to the stage of disease and performance status. [2005]

1.5.14Consider stent insertion for the immediate relief of severe symptoms of superior vena caval obstruction or following failure of earlier treatment. [2005]

Managing brain metastases

1.5.15Offer dexamethasone to people with symptomatic brain metastases and reduce to the minimum necessary maintenance dose for symptomatic response. [2011]

1.5.16For guidance on management of brain metastases, see the section on management of confirmed brain metastases in the NICE guideline on brain tumours. [2019]

Bone metastases

1.5.17Administer single-fraction radiotherapy to people with bone metastasis who need palliation and for whom standard analgesic treatments are inadequate. [2005]

1.5.18For more guidance on preventing complications from bone metastases, see the NICE technology appraisal guidance on denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours. [2019]

Managing other symptoms: weight loss, loss of appetite, difficulty swallowing, fatigue and depression

1.5.19Other symptoms, including weight loss, loss of appetite, depression and difficulty swallowing, should be managed by multidisciplinary groups that include supportive and palliative care professionals. [2005]

1.6 Follow-up and patient perspectives

1.6.1Offer 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. [2011]

1.6.2Offer 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. [2011]

1.6.3Ensure that people know how to contact the lung cancer clinical nurse specialist involved in their care between their scheduled hospital visits. [2011]

1.6.4The 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. [2005]

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