Quality standard

Quality statement 4: Investigations

Quality statement 4: Investigations

Quality statement

Adults with lung cancer being considered for treatment with curative intent have investigations to accurately determine diagnosis and stage, and to assess lung function. [new 2019]

Rationale

Undergoing treatment with curative intent when lung cancer has already spread can reduce quality of life without increasing life expectancy. It is important that adults who are being considered for treatment with curative intent have accurate diagnosis and staging. This will ensure that the most appropriate treatment is provided. Risk assessment for people being considered for treatment with curative intent should include assessment of lung function because this is a good predictor of treatment outcomes.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

a) Evidence of local processes to record investigations to accurately determine diagnosis and stage and to assess lung function, for adults with lung cancer who are being considered for treatment with curative intent.

Data source: Local data collection, for example, local protocols.

b) Evidence of availability of positron‑emission tomography CT (PET‑CT) for adults with lung cancer who are being considered for treatment with curative intent.

Data source: Local data collection, for example, waiting times for PET‑CT (including results) for adults with lung cancer. NHS England's Implementing a timed lung cancer diagnostic pathway indicates that investigations should be complete by day 14 in the 28‑day pathway.

c) Evidence of availability of brain imaging for adults with non-small-cell lung cancer stage II or III who are being considered for treatment with curative intent.

Data source: Local data collection, for example, access to magnetic resonance imaging (MRI) and waiting times for brain imaging (including results) for adults with non-small-cell lung cancer. NHS England's Implementing a timed lung cancer diagnostic pathway indicates that investigations should be complete by day 14 in the 28‑day pathway.

Process

a) Proportion of adults with lung cancer treated with curative intent who had PET‑CT before starting treatment.

Numerator – the number in the denominator who had PET‑CT before starting treatment.

Denominator – the number of adults with lung cancer treated with curative intent.

Data source: Local data collection, for example, audit of patient records.

b) Proportion of adults with non-small-cell lung cancer stage II or III treated with curative intent who had brain imaging before starting treatment.

Numerator – the number in the denominator who had brain imaging before starting treatment.

Denominator – the number of adults with non-small-cell lung cancer stage II or III treated with curative intent.

Data source: Local data collection, for example, audit of patient records.

c) Proportion of adults with non-small-cell lung cancer treated with curative intent who had spirometry and transfer factor (TLCO) before starting treatment.

Numerator – the number in the denominator who had spirometry and TLCO before starting treatment.

Denominator – the number of adults with non-small-cell lung cancer treated with curative intent.

Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset includes data on diffusion capacity or TLCO, and forced expiratory volume (FEV1). Royal College of Physicians National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on completeness for FEV1 and FEV1% predicted for people with stage I or II lung cancer and performance status 0 to 1.

d) Proportion of adults with lung cancer who had clinical stage and performance status recorded.

Numerator – the number in the denominator who had clinical stage and performance status recorded.

Denominator – the number of adults with lung cancer.

Data source: Royal College of Physicians' National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on valid performance status and stage.

Outcome

1‑year survival rate for adults with lung cancer treated with curative intent.

Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.

What the quality statement means for different audiences

Service providers (such as secondary and tertiary care) ensure that processes are in place for adults with lung cancer who are being considered for treatment with curative intent to have investigations to accurately determine diagnosis and stage, and to check lung function. Providers ensure that adults with lung cancer do not start treatment with curative intent until the results of PET‑CT, brain imaging and lung function (if relevant) are available. Providers follow the NHS England lung cancer diagnostic pathway to ensure investigations are timely and do not lead to treatment being delayed.

Healthcare professionals (such as consultants, clinical nurse specialists and consultant radiographers) arrange for adults with lung cancer who are being considered for treatment with curative intent to have investigations to accurately determine diagnosis and stage, and to check lung function. Healthcare professionals give people information about the purpose of the investigations, and discuss the results with them, including what they might mean for their treatment.

Commissioners (such as clinical commissioning groups) commission services that ensure adults with lung cancer who are being considered for treatment with curative intent have investigations to accurately determine diagnosis and stage, and to check lung function. Commissioners ensure that providers have the equipment and capacity to carry out PET‑CT and brain imaging without delaying the start of treatment with curative intent.

Adults with lung cancer who may be able to have treatment to cure their cancer have scans to confirm the diagnosis and stage of the cancer, and tests to check how well their lungs are working. The results will help to identify the most suitable treatment.

Source guidance

Lung cancer: diagnosis and management. NICE guideline NG122 (2019), recommendations 1.3.4, 1.3.18, 1.3.19, 1.3.22 to 1.3.25 and 1.4.13

Definitions of terms used in this quality statement

Investigations to accurately determine diagnosis and stage, and to assess lung function

Investigations should include:

  • PET‑CT

  • Stage‑specific brain imaging for people with non-small-cell lung cancer

    • no brain imaging for people with stage I

    • contrast‑enhanced brain CT for people with stage II

    • contrast‑enhanced brain MRI for people with stage III

  • spirometry and TLCO for people with non-small-cell lung cancer

[NICE's guideline on lung cancer, recommendations 1.3.4, 1.3.23 to 1.3.25 and 1.4.13]

Treatment with curative intent for lung cancer

There are a variety of treatment options and combinations of treatment that aim to remove the tumour and effect a cure for adults with lung cancer. These include: surgery, radiotherapy, chemotherapy and chemoradiotherapy. The approach to treatment will depend on the type of lung cancer, the clinical stage of the tumour, the person's performance status, comorbidities and the person's choice. [NICE's guideline on lung cancer and expert opinion]