肺癌诊断和治疗.pdf
肺癌诊断和治疗.pdf
The diagnosis and treatment of lung cancer (update): full guideline (April 2011)
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Clinical Guideline
The diagnosis and treatment of lung
cancer (update)
Full Guideline
This guidance updates and replaces NICE clinical guideline 24 (published February
2005).
New and updated recommendations are included on communication, diagnosis and
staging, selection of patients with non-small-cell lung cancer (NSCLC) for treatment
with curative intent, surgical techniques, smoking cessation, combination treatment
for NSCLC, treatment of small-cell lung cancer (SCLC), managing endobronchial
obstruction, managing brain metastases and follow-up and patient perspectives.
New or updated sections of the guideline are highlighted by a bar in the right
hand margin.
Recommendations are marked as [2005], [2011] or [new 2011].
[2005] indicates that the evidence has not been updated and reviewed since 2005.
[2011] indicates that the evidence has been reviewed but no changes have been
made to the recommendation.
[new 2011] indicates that the evidence has been reviewed and the recommendation
has been added or updated.
The content of other sections has not been updated since the original
guideline. The original content of these sections (including the evidence and
recommendations) can be found in Appendix 10.
Please be aware that this is a partial update of an existing guideline, with the
integration of new and old sections. There are differences in the style of
wording between the 2005 and 2011 recommendations. This is because there
have been changes to how NICE style the wording of their recommendations
compared to 2005.
The diagnosis and treatment of lung cancer (update): full guideline (April 2011)
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Contents
Key priorities .......................................................................................................................... 4
Key research recommendations ............................................................................................. 5
Methodology........................................................................................................................... 7
Algorithms ............................................................................................................................ 17
1 Epidemiology .............................................................................................................. 20
1.1 Introduction ................................................................................................................. 20
1.2 Incidence ..................................................................................................................... 20
1.3 Sex variation ............................................................................................................... 22
1.4 Histological subtypes................................................................................................... 23
1.5 Socio-economic status (SES) ...................................................................................... 24
1.6 Ethnic variation............................................................................................................ 25
1.7 Stage and performance status .................................................................................... 26
1.8 Treatment received ..................................................................................................... 28
1.9 Survival ....................................................................................................................... 33
1.10 Facilities available at NHS Trusts in England and Wales ............................................. 37
1.11 Lung Cancer Specialist Nurse .................................................................................... 38
2 Access to services and referral ................................................................................... 48
2.1 The importance of early diagnosis ............................................................................... 48
2.2 Referral and indications for chest radiography ............................................................ 49
3 Communication ........................................................................................................... 51
4 Diagnosis and Staging ................................................................................................ 56
4.1 Introduction ................................................................................................................. 56
4.2 Effectiveness of Diagnostic and Staging Investigations ............................................... 57
4.3 Sequence of investigations.......................................................................................... 60
4.4 Organisational factors relevant to diagnosis and staging ............................................. 70
5 Treatment with curative intent for NSCLC ................................................................... 79
5.1 Selection of patients with NSCLC for treatment with curative intent ............................. 79
5.2 Pulmonary optimisation ............................................................................................... 83
5.3 Options for treatment with curative intent for patients with NSCLC .............................. 87
5.4 Radiotherapy with curative intent ................................................................................ 92
5.5 Combination Treatment for NSCLC ............................................................................. 95
5.6 Prophylactic Cranial Irradiation in NSCLC ................................................................. 103
6 Chemotherapy for NSCLC ........................................................................................ 114
7 Treatment of small cell lung cancer (SCLC) .............................................................. 115
7.1 Staging of SCLC ....................................................................................................... 115
7.2 Assessment of patients with SCLC ............................................................................ 115
7.3 First line treatment of patients with limited stage disease SCLC (broadly staged
as T1-4, N0-3, M0) .................................................................................................... 116
7.4 Surgical treatment for patients with SCLC ................................................................. 119
7.5 First line treatment for extensive stage disease small cell lung cancer (broadly
staged as T1-4, N0-3, M1 a/b) ................................................................................... 121
7.6 Second line treatment for patients with SCLC who relapse after primary
treatment ................................................................................................................... 127
8 Palliative interventions and Supportive and Palliative Care ....................................... 136
8.1 Common symptoms of lung cancer ........................................................................... 137
8.2 Palliative Radiotherapy .............................................................................................. 137
8.3 Management of endobronchial obstruction ................................................................ 138
8.4 Other treatments with palliative intent ........................................................................ 140
8.5 Management of brain metastases ............................................................................. 141
8.6 Spinal Cord Compression ......................................................................................... 143
8.7 Hypercalcaemia, Bone Pain and Pathological Fractures ........................................... 143
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The diagnosis and treatment of lung cancer (update): full guideline (April 2011)
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8.8 Other symptoms: weight loss, loss of appetite, difficulty swallowing, fatigue and
depression ................................................................................................................ 144
9 Follow-up and patient perspectives ........................................................................... 147
9.1 The Patient‟s Perspective .......................................................................................... 148
Appendix 1: Needs assessment questionnaire sent to LHB‟s in Wales and lung
cancer leads in England. ........................................................................................... 152
Appendix 2: Summary of the 7th edition of the TNM staging system in comparison
with the 6th edition. .................................................................................................... 155
Appendix 3: Questions for histopathologists regarding update of nice lung cancer
guideline.................................................................................................................... 156
Appendix 4: Economic model to compare different testing strategies to stage the
mediastinum in patients with NSCLC ........................................................................ 158
Appendix 5: Abbreviations .................................................................................................. 187
Appendix 6: Glossary ......................................................................................................... 188
Appendix 7: Guideline Scope ............................................................................................. 201
Appendix 8: List of topics covered by each chapter ............................................................ 205
Appendix 9: People and organisations involved in production of the guideline ................... 206
Appendix 10: The 2005 lung cancer guideline, including all original sections that have
been updated by the 2011 document (see separate document)
Appendix 11: Full evidence review (see separate document)
The diagnosis and treatment of lung cancer (update): full guideline (April 2011)
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Key priorities
1. The public needs to be better informed of the symptoms and signs that are
characteristic of lung cancer, through coordinated campaigning to raise
awareness. [2005]
2. Ensure that a lung cancer clinical nurse specialist is available at all stages of
care to support patients and carers. [NEW 2011]
3. Choose investigations that give the most information about diagnosis and
staging with the least risk to the patient. Think carefully before performing a
test that gives only diagnostic pathology when information on staging is also
needed to guide treatment. [NEW 2011]
4. Offer PET-CT, or EBUS-guided TBNA, or EUS-guided FNA or non-
ultrasound-guided TBNA as the first test for patients with an intermediate
probability of mediastinal malignancy (lymph nodes between 10 and 20
mm maximum short axis on CT) who are potentially suitable for treatment with
curative intent. [NEW 2011].
5. Offer patients with NSCLC who are medically fit and suitable for treatment
with curative intent, lobectomy (either open or thoracoscopic) as the treatment
of first choice. For patients with borderline fitness and smaller tumours (T1a-b,
N0, M0), consider lung parenchymal-sparing operations (segmentectomy or
wedge resection) if a complete resection can be achieved. [NEW 2011]
6. Radical radiotherapy is indicated for patients with stage I, II or III NSCLC who
have good performance status (WHO 0,1) and whose disease can be
encompassed in a radiotherapy treatment volume without undue risk of
normal tissue damage1. [2005]
7. Ensure all patients potentially suitable for multimodality treatment (surgery,
radiotherapy and chemotherapy in any combination) are assessed by a
thoracic oncologist and by a thoracic surgeon. [NEW 2011]
8. Arrange for patients with small-cell lung cancer (SCLC) to have an
assessment by a thoracic oncologist within 1 week of deciding to recommend
treatment [NEW 2011].
9. Every cancer network should ensure that patients have rapid access to a
team capable of providing interventional endobronchial treatments [NEW
2011].
10. Offer all patients an initial specialist follow-up appointment within 6 weeks of
completing treatment to discuss ongoing care. Offer regular appointments
thereafter, rather than relying on patients requesting appointments when they
experience symptoms. [NEW 2011]
1 The GDG recognises that radiotherapy techniques have advanced considerably since the 2005 guideline and
centres would reasonably wish to offer these techniques (including SBRT and 4-D planning) to patients. These
treatments have the advantage of reducing the risk of damage to normal tissue (estimated by using measurements
such as V20).
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The diagnosis and treatment of lung cancer (update): full guideline (April 2011)
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Key research recommendations
1. Further studies should be performed into factors that predict successful
outcome in treatment with curative intent. Studies should include fitness
parameters and functional imaging.
Despite much research into factors that predict a successful outcome after
treatment with curative intent it is still not clear how these relate to the patient
with borderline fitness. To ensure that fitness assessment is robust, consistent
and meaningful, the place of exercise testing, lung function testing and functional
imaging should be clearly defined by appropriately designed trials.
2. Patients with non-bulky single zone N2 disease should be considered for
trials of surgery with or without multimodality treatment. Outcomes should
include mortality and 5-year survival.
A number of randomised controlled trials have been evaluated in this guideline
that have shown that surgery, as part of multimodality treatment, does not
worsen prognosis in patients with N2 disease. However, these studies did not
distinguish between those patients who might intuitively benefit from surgery (a
limited number of nodes involved and/or a single zone affected) and those with
more extensive disease and potentially less favourable biology (many nodes
involved and/or multiple zones affected). Further trials are needed to establish
the role of surgery in this heterogeneous group.
3. Research should be undertaken into the benefits of pulmonary
rehabilitation, optimisation of drug treatment and enhanced recovery
programmes before and after surgery. Outcomes should include mortality,
survival, pulmonary complications, pulmonary function and quality of life
(including assessment by EQ-5D).
There is some evidence that pulmonary rehabilitation, optimisation of drug
treatment and enhanced recovery programmes are effective patients undergoing
surgery for some conditions but none for patients undergoing surgery for lung
cancer. Fitness for surgery, and the ability of the patient to recover following
surgery are key factors in the success of this treatment for lung cancer. The
effectiveness of interventions to improve these factors should be evaluated.
4. Research should be considered into dose escalation in radiotherapy with
curative intent, including stereotactic body irradiation (SBRT). Outcomes
should include mortality, pulmonary complications, pulmonary function
and validated quality of life measures (including assessment by EQ-5D).
There have been considerable technological advances in radiotherapy
equipment that has allowed radiotherapy to be more accurately delivered to the
tumour and hence less damaging to normal tissues. This has allowed new
regimes to be developed, including SBRT, which have not been evaluated
adequately for their efficacy and toxicity.
5. Randomised controlled trials should be conducted to examine the value of
imaging modalities and other interventions in the monitoring of response
and recurrent disease.
Patients with lung cancer have high recurrence rates even when treated with
curative intent. It is not known whether imaging modalities and other
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