Lung cancer: diagnosis and management

Why the committee made the recommendations

How the recommendations might affect practice

The recommendations on PET-CT reflect current practice, so will not incur an extra cost.

The recommendations on EBUS-TBNA and EUS-FNA will reinforce best practice and result in a more streamlined diagnostic service with more timely diagnosis and staging.

The surgical mediastinal staging recommendation will also reinforce best practice and restrict this procedure to people most likely to benefit.

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Why the committee made the recommendations

Brain imaging is helpful before starting treatment with curative intent, because if brain metastases are detected then the treatment plan is likely to change. However, routine brain imaging is expensive, and the evidence showed that it does not always offer a good balance of benefits and costs.

In people with stage II and IIIA disease, the benefits of brain imaging outweigh the costs because:

In people with clinical stage I NSCLC and no neurological symptoms, the prevalence of detectable brain metastases is fairly low (around 4%) compared with people with stage II or IIIA disease. People with stage I NSCLC who do have brain metastases often still have radical lung treatment, which is much more rarely the case for people with stage IIIA NSCLC. Overall, the lower prevalence of metastases and smaller reduction in numbers of people having radical treatment mean that the benefits of brain imaging in this population are too low to justify the costs.

The 2018 review only examined the clinical and cost effectiveness of imaging after the treatment plan has been decided, but the committee noted that it could be more efficient to conduct CT brain imaging alongside initial staging CT. With this in mind, the committee made a recommendation for research on routine brain imaging with CT at initial diagnosis and/or staging.

How the recommendations might affect practice

Practice in this area is variable. The committee estimated that the recommendations will increase the number of people who have brain imaging. In turn, they thought this should prevent the use of treatment options (such as lobectomy and sublobar resection) in some patients for whom it is not expected to be beneficial. The recommendations may also lead to an increase in radical radiotherapy, stereotactic radiosurgery and brain surgery. These treatments would be expected to improve the person's prognosis, although each treatment would carry its own risks and side effects.

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Why the committee made the recommendations

For people with non-small-cell lung cancer (NSCLC) who are well enough and for whom treatment with curative intent is suitable, the evidence showed that lobectomy provides better survival outcomes than stereotactic ablative radiotherapy (SABR). Lobectomy is a good compromise between preserving pulmonary function and being more likely to remove cancerous cells compared with sublobar resection.

For people with stage I–IIA (T1a–T2b, N0, M0) NSCLC, the evidence showed that:

For people with stage IIIA or IIIB NSCLC who cannot tolerate chemoradiotherapy or who decline it, the evidence was not strong enough to recommend conventional radiotherapy over hyper-fractionated regimens or vice versa. However, people who cannot tolerate chemoradiotherapy may also be unable to tolerate radical radiotherapy, so this will not be an option for everyone with stage IIIA or IIIB NSCLC. For an explanation of the recommendations covering surgery in this group, see the rationale on management of stage IIIA-N2 NSCLC.

55 Gy in 20 fractions is the most common conventional radical radiotherapy regimen in the UK. If conventionally fractionated radiotherapy is used, a total radiation dose of 60 Gy provides better survival outcomes and fewer adverse events than 74 Gy. A total dose of 60 to 66 Gy is also normal NHS practice.

There are not many randomised controlled trials comparing SABR with surgery (lobectomy or sublobar resection). SABR is non-invasive, so if it is as effective as surgery then it may be a preferable option for many people with lung cancer. There are also various factors that may make SABR less costly than surgery. For example, it is usually delivered as outpatient treatment. There might also be subgroups for whom different forms of surgery or SABR might be the most cost-effective options. The committee made a recommendation for research on SABR compared with surgery to investigate these uncertainties.

How the recommendations might affect practice

The new recommendations on SABR are a change from the 2011 guideline and improve choice for people with NSCLC. However, practice has also changed since 2011, and SABR is now widely used, so implementing the recommendations may not involve a significant change in practice. The remaining changes to the recommendations reflect current practice.

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Why the committee made the recommendations

The available evidence showed that chemoradiotherapy and surgery are more effective than chemoradiotherapy alone in people who are well enough for surgery and when the disease is operable. For chemotherapy and surgery, there was no evidence that survival outcomes were better than for chemoradiotherapy, so the additional costs of including surgery outweighed the benefits.

The key benefit associated with chemoradiotherapy and surgery is the longer progression‑free survival time. An analysis of multiple trials showed improved progression-free survival and cost effectiveness for chemoradiotherapy with surgery, compared with chemoradiotherapy alone. There was an 89% probability that chemoradiotherapy and surgery improved average overall survival time compared with chemoradiotherapy. However, the evidence in favour of chemoradiotherapy and surgery involved indirect comparisons, and no head-to-head trials showed meaningful differences in overall survival for any of the interventions. And as with any major surgery, there is a perioperative mortality risk for people who have chemoradiotherapy and surgery.

The 3 to 5 week wait for surgery is recommended to give people time to recover from the chemoradiotherapy.

Chemoradiotherapy with surgery is not often offered in current practice. In addition, there are specific factors to take into account when offering all these treatments together. Therefore, multidisciplinary teams providing it should have expertise both in the combined therapy, and in all the individual components.

Immunotherapy has been shown to be effective in a variety of NSCLC indications but there is currently no evidence on whether it is clinically or cost effective for people with stage IIIA-N2 NSCLC following surgery. The committee made a recommendation for research on immunotherapy after multimodality treatment to address this.

How the recommendations might affect practice

The committee felt that chemoradiotherapy and surgery is offered far less often than chemoradiotherapy alone or chemotherapy and surgery for people with NSCLC stage IIIA-N2. Therefore, these recommendations could lead to a change in current practice.

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Why the committee changed the recommendations

The evidence showed a survival benefit from twice-daily radiotherapy compared with once-daily. However, the committee agreed that some people with small-cell lung cancer will not be well enough to tolerate twice-daily radiotherapy, so they recommended giving people the option of once-daily radiotherapy.

The committee noted that, in practice, radiotherapy is not started in chemotherapy cycle 1, because this is when planning for the radiotherapy often takes place (see the recommendation on twice-daily radiotherapy with concurrent chemotherapy in the section on first-line treatment for limited-stage disease small-cell lung cancer). However, there was no new evidence on when to start radiotherapy, so the 2019 recommendation on this is the same as the original 2011 recommendation.

There were limited data available on whether continuous radiotherapy with concurrent chemotherapy was more effective than alternating radiotherapy and chemotherapy. Because of the limited data, and the committee's experience that people prefer to complete treatment as quickly as possible, the 2019 recommendation on concurrent therapy (see the recommendation on twice-daily radiotherapy with concurrent chemotherapy) is the same as the 2011 recommendation.

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Why the committee made the recommendations

How the recommendations might affect practice