Treatment | Lung cancer: diagnosis and management | Guidance

1.4 Stop smoking interventions and services

1.4.1

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

1.4.2

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

1.4.3

Offer nicotine replacement therapy and other therapies to help people to stop smoking in line with the NICE guideline on tobacco: preventing uptake, promoting quitting and treating dependence and the NICE technology appraisal guidance on varenicline for smoking cessation. [2011]

1.4.4

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

1.5 Assessing people with non-small-cell lung cancer for treatment with curative intent

Perioperative mortality

1.5.1

When 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

1.5.2

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

1.5.3

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

1.5.4

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

1.5.5

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

1.5.6

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

1.5.7

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

1.5.8

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

Lung function

1.5.9

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

1.5.10

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

1.5.11

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

1.5.12

Offer 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]

1.5.13

Consider 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]

1.5.14

Consider 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

1.5.15

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

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

Surgery

1.6.1

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

1.6.2

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

1.6.3

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

1.6.4

For 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

1.6.5

For 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

1.6.6

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

1.6.7

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

1.6.8

For 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]

1.6.9

For 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]

1.6.10

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

Radiotherapy fractionation

1.6.11

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

1.6.12

If 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 these 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.

1.7 Combination treatment for non-small-cell lung cancer

1.7.1

Consider 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]

1.7.2

Ensure 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]

1.7.3

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

1.7.4

Consider 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]

1.7.5

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

1.7.6

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

1.7.7

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

1.7.8

Treat 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]

1.7.9

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

1.7.10

Discuss 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]

1.7.11

For 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]

1.7.12

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

1.7.13

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

For a short explanation of why the committee made these 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.

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

We have produced treatment pathways bringing together NICE recommended treatment options from this guideline and relevant technology appraisal guidance on advanced non-small-cell lung cancer (squamous and non-squamous). The treatment pathways cover the recommended treatment options at each decision point.

These are available to view as individual pathways (linked below), or grouped together in a single interactive PDF of all treatment pathways for squamous and non-squamous advanced non-small-cell lung cancer.

We have also produced fully accessible summaries of the treatment pathways.

Squamous non-small-cell lung cancer

Non-squamous non-small-cell lung cancer

No targetable mutations, PD-L1 less than 50%

Systemic anti-cancer therapy: treatment options for people with non-squamous non-small-cell lung cancer, with no targetable mutations and PD-L1 less than 50%

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with non-squamous non-small-cell lung cancer, with no targetable mutations and PD-L1 less than 50%

No targetable mutations, PD-L1 50% or higher

Systemic anti-cancer therapy: treatment options for people with non-squamous non-small-cell lung cancer, with no targetable mutations and PD-L1 50% or higher

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with non-squamous non-small-cell lung cancer, with no targetable mutations and PD-L1 50% or higher

RET fusion positive, PD-L1 less than 50%

Systemic anti-cancer therapy: treatment options for people with RET fusion positive non-squamous non-small-cell lung cancer, with PD-L1 less than 50%

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with RET fusion positive non-squamous non-small-cell lung cancer, with PD-L1 less than 50%

RET fusion positive, PD-L1 50% or higher

Systemic anti-cancer therapy: treatment options for people with RET fusion positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with RET fusion positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

NTRK fusion positive, PD-L1 less than 50%

Systemic anti-cancer therapy: treatment options for people with NTRK fusion positive non-squamous non-small-cell lung cancer, with PD-L1 less than 50%

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with NTRK fusion positive non-squamous non-small-cell lung cancer, with PD-L1 less than 50%

NTRK fusion positive, PD-L1 50% or higher

Systemic anti-cancer therapy: treatment options for people with NTRK fusion positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with NTRK fusion positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

KRAS G12C positive, PD-L1 less than 50%

Systemic anti-cancer therapy: treatment options for people with KRAS G12C positive non-squamous non-small-cell lung cancer, with PD-L1 less than 50%

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with KRAS G12C positive non-squamous non-small-cell lung cancer, with PD-L1 less than 50%

KRAS G12C positive, PD-L1 50% or higher

Systemic anti-cancer therapy: treatment options for people with KRAS G12C positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with KRAS G12C positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

METex14 skipping alteration, PD-L1 less than 50%

Systemic anti-cancer therapy: treatment options for people with METex14 skipping alteration non-squamous non-small-cell lung cancer, with PD-L1 less than 50%

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with METex14 skipping alteration non-squamous non-small-cell lung cancer, with PD-L1 less than 50%

METex14 skipping alteration, PD-L1 50% or higher

Systemic anti-cancer therapy: treatment options for people with METex14 skipping alteration non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with METex14 skipping alteration non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

BRAF V600 positive, PD-L1 less than 50%

Systemic anti-cancer therapy: treatment options for people with BRAF V600 positive non-squamous non-small-cell lung cancer, with PD-L1 less than 50%

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with BRAF V600 positive non-squamous non-small-cell lung cancer, with PD-L1 less than 50%

BRAF V600 positive, PD-L1 50% or higher

Systemic anti-cancer therapy: treatment options for people with BRAF V600 positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

Fully accessible summary of Systemic anti-cancer therapy: treatment options for people with BRAF V600 positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

ROS-1 positive

Systemic anti-cancer therapy: treatment options for people with ROS-1 positive non-squamous non-small-cell lung cancer

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with ROS-1 positive non-squamous non-small-cell lung cancer

EGFR-TK positive

Systemic anti-cancer therapy: treatment options for people with EGFR-TK positive non-squamous non-small-cell lung cancer

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with EGFR-TK positive non-squamous non-small-cell lung cancer

ALK positive

Systemic anti-cancer therapy: treatment options for people with ALK positive non-squamous non-small-cell lung cancer

Fully accessible summary of systemic anti-cancer therapy: treatment options for people with ALK positive non-squamous non-small-cell lung cancer

1.9 Assessing people with small-cell lung cancer

1.9.1

Arrange 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]

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

1.10.1

Offer 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]

1.10.2

Offer 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]

1.10.3

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

1.10.4

Offer 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]

1.10.5

Offer 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 these 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.

1.11 Surgery for small-cell lung cancer

1.11.1

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

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

1.12.1

Offer 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]

1.12.2

Assess 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]

1.12.3

Consider 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]

1.12.4

Consider 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 these 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.

1.13 Maintenance treatment for small-cell lung cancer

1.13.1

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

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

1.14.1

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

1.14.2

Inform 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]

1.14.3

Offer 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]

1.14.4

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

Topotecan

1.14.5

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