肺癌诊断和治疗.pdf

格式: pdf 页数: 220 文件大小: 2MB 侵权/举报
肺癌诊断和治疗.pdf

肺癌诊断和治疗.pdf

格式: pdf 页数: 220 文件大小: 2MB
肺癌诊断和治疗.pdf The diagnosis and treatment of lung cancer (update): full guideline (April 2011) Page 1 of 220 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) Page 2 of 220 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 U p d ate d 2 0 1 1 The diagnosis and treatment of lung cancer (update): full guideline (April 2011) Page 3 of 220 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) Page 4 of 220 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). U p d a te d 2 0 1 1 The diagnosis and treatment of lung cancer (update): full guideline (April 2011) Page 5 of 220 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 U p d a te d 2 0 1 1 ...