"Other than skin cancer, lung cancer is now the most common cancer and is the most frequent cause of death from cancer in both men and women," write ACCP chair W. Michael Alberts, MD, FCCP, and colleagues. "In recognition of the importance of lung cancer in the population and with the rise of evidence-based medicine as a basis for diagnosing the disease and managing those afflicted, in the year 2000 the ACCP, through its Health and Science Policy Committee, commissioned the development of evidence-based guidelines on the diagnosis and management of lung cancer.... Fortunately, the pace of discovery in the diagnosis and management of lung cancer has quickened."
The new guidelines, which update and expand those first published in January 2003, were developed by nearly 100 voluntary faculty and ACCP staff, using rigorous adherence to formal guideline methodology, attention to process detail, and the newly developed ACCP grading system. The updated recommendations incorporate findings published in the literature since 2002.
New chapters added to the second edition guidelines deal with diagnostic surgical pathology in lung cancer, bronchioloalveolar lung cancer, and complementary therapies and integrative oncology in lung cancer. Topics that have been extensively revised to reflect recent advances include screening for lung cancer, criteria for determining when a pulmonary nodule is lung cancer, management of bronchial intraepithelial neoplasia/early central airways lung cancer, palliative care consultation, quality-of-life measurement, and bereavement for end-of-life care in patients with lung cancer.
Some of the recommendations include:
- The use of β-carotene supplementation is not recommended for chemoprevention of lung cancer in individuals with a greater than 20–pack-year history of smoking or with a history of lung cancer (grade of recommendation, 1A).
- The guidelines recommend against the use of serial chest radiographs or the use of single or serial sputum cytologic evaluation to screen for the presence of lung cancer (1A).
- Reporting histologic type, tumor size and location, tumor grade (if appropriate), lymphovascular invasion, involvement of pleura, surgical margins, and status and location of lymph nodes by station is recommended for pathological diagnosis of lung cancer (1B).
- Small-cell lung carcinoma (SCLC) and non–small-cell carcinoma parenchymal-based tumors should be differentiated, using a diagnostic panel of immunohistochemical assays if needed (1B).
- In every patient with a solitary pulmonary nodule (SPN) visible on chest radiography, previous chest radiographs and other relevant imaging tests should be reviewed (1C), and computed tomography (CT) of the chest should be performed, preferably with thin sections through the nodule (1C).
- Tissue diagnosis is recommended, unless specifically contraindicated, for an SPN that shows clear evidence of growth on imaging tests (1C).
- An SPN that is stable on imaging tests for at least 2 years does not require additional diagnostic evaluation, except that patients with pure ground-glass opacities on CT should have a longer duration of annual follow-up (2C).
- An SPN that is calcified in a clearly benign pattern does not require additional diagnostic evaluation (1C).
- When SCLC is suspected from radiographic and clinical findings, the diagnosis should be confirmed by the easiest method (sputum cytology, thoracentesis, fine-needle aspirate, bronchoscopy including transbronchial needle aspiration and endobronchial ultrasound-needle aspiration, endoscopic ultrasound-needle aspiration), based on the patient's presentation (1C). When there is an accessible pleural effusion, thoracentesis is recommended (1C). If pleural fluid cytology findings are negative after at least 2 thoracenteses, thoracoscopy should be performed if establishing the cause of the pleural effusion is thought to be clinically important (1C).
- A multidisciplinary team including a thoracic surgeon specializing in lung cancer, medical oncologist, radiation oncologist, and pulmonologist should evaluate patients with lung cancer for curative surgical resection (1C). Lung resection surgery should not be denied based on age alone (1B). Patients with major factors for increased perioperative cardiovascular risk should undergo a preoperative cardiologic evaluation (1C). Spirometry is recommended for patients being considered for lung cancer resection (1C).
- Patients with known or suspected non-SCLC (NSCLC) who are eligible for treatment should have a CT scan of the chest with contrast including the upper abdomen, liver, and adrenal glands (1B). Those with enlarged discrete mediastinal lymph nodes on CT (> 1 cm in short axis) and no evidence of metastatic disease should have further evaluation of the mediastinum before definitive treatment of the primary tumor (1B).
- Surgical resection is recommended for patients with clinical stage I and II NSCLC and no medical contraindication (1A). Even if these patients are being considered for nonsurgical therapies, such as percutaneous ablation or stereotactic body radiation therapy, they should be evaluated by a thoracic surgical oncologist with extensive experience in lung cancer (1B). Lobectomy or greater resection is preferred to sublobar resection (wedge or segmentectomy) if patients are medically fit (1A).
- In patients with stage IA NSCLC, adjuvant chemotherapy is not routinely recommended outside the setting of a clinical trial (1A). Patients with completely resected stage IB NSCLC should not routinely receive adjuvant chemotherapy (1B). Platinum-based adjuvant chemotherapy is recommended for patients with completely resected stage II NSCLC and good performance status (1A).
- Curative intent fractionated radiotherapy is recommended for patients with stage I or II NSCLC who are not candidates for surgery or who refuse surgery (1B).
To differentiate pleural adenocarcinoma from pleural-based malignant mesothelioma, a structured approach using a limited panel of histochemical and immunohistochemicalassays is recommended to increase the diagnostic accuracy; ultrastructural analysis and other studies may be needed in more challenging cases (1B).
Lung cancer is the most common cancer and is the most frequent cause of death from cancer in both men and women. In 2003, the ACCP first published guidelines for the diagnosis and management of lung cancer. However, many recent changes have occurred in the diagnosis and management of lung cancer, resulting in a need for updated guidelines to reflect these changes.
The aim of this article is to report on the second edition of ACCP evidence-based, clinical practice guidelines for the diagnosis and management of lung cancer.
The Study Highlights section highlights the chapters that have been extensively updated; these include "Screening for Lung Cancer," "Management of Patients with Pulmonary Nodules," "Palliative Care Consultation," "Quality of Life Measurement," and "Bereavement for End-of-Life Care in Patients with Lung Cancer."
- Low-dose helical CT, serial chest radiographs, and single or serial sputum cytologic evaluation are not recommended to screen for the presence of lung cancer.
- When pathologically diagnosing lung cancer, the reporting of histologic type, tumor size and location, tumor grade (if appropriate), lymphovascular invasion, involvement of pleura, surgical margins, and status and location of lymph nodes by station is recommended.
- Treatment of Patients With Pulmonary Nodules
- In every patient with an SPN, it is recommended that clinicians estimate the pretest probability of malignancy.
- In patients who have an SPN that shows clear evidence of growth on imaging tests, a tissue diagnosis should be obtained unless contraindicated.
- In patients with a low to moderate test probability of malignancy (5% - 60%) and an indeterminate SPN that measures at least 8 to 10 mm in diameter, fluorodeoxyglucose positron emission tomography should be performed to characterize the nodule.
- Patients with an indeterminate SPN that measures at least 8 to 10 mm who undergo observation need serial CT scans repeated at least at 3, 4, 12, and 24 months.
- Patients with an indeterminate SPN that measures at least 8 to 10 mm and who are candidates for curative treatments need transthoracic needle biopsy, especially for peripheral nodules, or bronchoscopy in the following circumstances: when the clinical pretest probability and findings on imaging tests are discordant, when a benign diagnosis requiring specific medical treatment is suspected, and when a fully informed patient desires proof of a malignant diagnosis prior to surgery.
- In surgical candidates with an indeterminate SPN that measures at least 8 to 10 mm in diameter, surgical diagnosis is preferred when the clinical probability of malignancy is moderate to high (> 60%), when the nodule is hypermetabolic by fluorodeoxyglucose positron emission tomographic imaging, and when the fully informed patient prefers undergoing definitive diagnostic procedure.
- For the patient with malignant SPN who is not a surgical candidate and who prefers treatment, referral for external beam radiation or to a clinical trial of an experimental treatment such as stereotactic radiosurgery or radiofrequency ablation is recommended.
- For surgical candidates with subcentimeter nodules who have no risk factors or have 1 or more risk factors for lung cancer, the frequency and duration of follow-up (preferably with low-dose CT) should depend on the size of the nodule.
- In surgical candidates with a solitary pulmonary metastasis, a pulmonary metastasectomy is recommended if there is no evidence of extrapulmonary malignancy and there is no better available treatment.
- All patients with advanced lung cancer (and their families) should have palliative care integrated into their treatment.
- Clinicians of dying patients with lung cancer should encourage caregivers to maintain a healthy lifestyle during the period of caregiver burden.
- Clinicians of patients dying from lung cancer should honor rituals of death and mourning in a culturally sensitive manner.
Pearls for Practice
- It is not recommended to screen for lung cancer using low-dose helical CT, serial chest radiographs, and/or single or serial sputum cytologic evaluation.
- Important factors regarding the management of pulmonary nodules include the pretest probability of malignancy, evidence of growth of the SPN, the determinate/indeterminate nature of the SPN, and the surgical candidacy of the patient.