Editorials

Managing patients with lung cancer

New guidelines should improve standards of care

Lung cancer is the commonest cancer in the United Kingdom and also the commonest cause of death from cancer, with around 37 000 deaths each year.¹ Despite this, it remains the Cinderella of common solid tumours, and because most patients are elderly and eventually succumb to the disease the management of patients is often afflicted by an unjustified sense of therapeutic nihilism. Both within and between countries there is greater variation in clinical practice and outcomes for patients with lung cancer than can be justified by factors such as case mix alone, ^{2 3} suggesting that clinicians use different information to inform treatment decisions. Evidence based clinical practice guidelines such as those recently published by the Royal College of Radiologists' clinical oncology information network (COIN) for the non-surgical management of lung cancer,⁴ and similar guidelines produced by other organisations, ^{5 6} should help clinicians make better decisions, thereby reducing inappropriate variation and improving patient care.

The COIN guidelines identify the most important clinical questions in the management of patients with lung cancer and make recommendations about these as well as the process of patient care. They are not prescriptive, but should guide clinicians in making relevant interventions. The strength of the evidence for the effectiveness of given interventions is summarised, making the rationale behind recommendations understandable. The guidelines identify those patients who are most likely to benefit from a particular intervention and indicate where no satisfactory standard of care is available and when clinical trials are appropriate. By identifying gaps in current knowledge, they should also help to prioritise research.

Modern cancer care should be a multidisciplinary process. The guidelines recommend that the lung cancer team should be involved in managing all patients with a working diagnosis of lung cancer and that pathological confirmation should be sought in all patients unless review by a member of the team has indicated that it would not be appropriate. Such a decision is usually made because the patient is unlikely to benefit from treatment. Most patients with lung cancer receive treatment as outpatients, allowing them to spend most of their time at home. The need for good communication between the lung cancer team and the primary care team is highlighted.

Lung cancer is divided into two main categories: small cell lung cancer, which accounts for around a quarter of all cases, and non-small cell lung cancer, which accounts for the remainder. Non-small cell lung cancer consists of several different pathological types (squamous cell, adenocarcinoma, large cell), which respond to treatment in a similar way and are managed in the same way. Treatment for small cell and non-small cell lung cancer is very different.

Surgery is the only curative treatment for non-small cell lung cancer, and this should be considered in all patients, even though overall fewer than a fifth are suitable for surgery¹ and, among those who undergo surgery, fewer than half will survive five years.⁷ For patients undergoing surgery, the benefit of neoadjuvant or adjuvant treatment with chemotherapy or radiotherapy remains uncertain for most, and these treatments are recommended only in the context of a clinical trial. Neverthless, postoperative radiotherapy may reduce locoregional recurrence, and the guidelines suggest that it should be considered for patients with macroscopic or microscopic residual disease.

Patients with stage I or II non-small cell lung cancer and a good performance status, who are inoperable for medical reasons, may be cured by radical radiotherapy. The guidelines support this treatment, even in patients in whom pathological confirmation cannot be obtained, provided there is a clear radiological diagnosis.

The guidelines recommend that patients with good performance status who are staged by computed tomography as having locoregionally advanced disease (stage III) and considered inoperable by a thoracic surgeon should be considered for radical radiotherapy. Continuous hyperfractionated accelerated radiotherapy (CHART) is associated with improved survival and completed in a much shorter time than conventional radiotherapy (12 days v 6 weeks),⁸ but this treatment is not widely available at present, so conventionally fractionated radical radiotherapy is also recommended.

For most patients with unresectable and therefore incurable non-small cell lung cancer the emphasis of treatment is on controlling symptoms and maintaining quality of life. For patients with a poor prognosis with chest symptoms such as cough, haemoptysis, or pain, palliative radiotherapy is widely considered to be the standard treatment, and hypofractionated regimensfor example, a single fraction or two fractions one week apartare recommended. Selected patients with good performance status and no obvious systemic metastases should be considered for higher dose regimens, as these may be associated with a modest survival benefit. Although there is increasing evidence of a small survival benefit from palliative chemotherapy in patients with advanced non-small cell lung cancer (stage IIIB and IV), this treatment is potentially toxic, and in the light of the generally poor quality of life information available the guidelines suggest that treatment should normally be offered in the context of a clinical trial.

Small cell lung cancer is a rapidly progressive tumour, and untreated patients survive on average for less than three months.⁹ Two thirds of patients present with extensive disease, and the remainder have limited disease with no sign of cancer beyond one side of the chest. Surgery is rarely an option in small cell lung cancer owing to the systemic nature of the disease. All patients should be considered for chemotherapy, which can provide rapid palliation of symptoms and prolong survival, although recurrence is frequent.⁹ Because this disease can progress rapidly, it is recommended that all patients referred for chemotherapy should be seen within a week of referral and that chemotherapy should start within two weeks of a confirmed histological diagnosis.

Patients with small cell lung cancer can be divided into those with good and poor prognoses on the basis of performance status, extent of disease, and concentrations of serum sodium, alkaline phosphatase, aspartate transaminase, and lactate dehydrogenase. For those with a good prognosis the guidelines recommend six courses of intravenous combination chemotherapy, unless there is evidence of progressive disease or intolerable toxicity. Patients with a poor prognosis should be treated similarly, although the number of courses may need to be reduced to minimise toxicity. Consolidation thoracic radiotherapy increases local control and survival in patients with limited disease who have achieved a complete response to chemotherapy.¹⁰ The guidelines recommend offering this to all such patients with a good performance status, at the completion of chemotherapy, along with prophylactic cranial irradiation, which has been shown to reduce the incidence of cerebral metastases and increase survival in patients with limited disease.¹¹

Integrating these guidelines into clinical practice and evaluating their impact on practice and patient outcomes is extremely important. Quality standards are identified to help users to audit their performance against the guideline recommendations, and a core clinical data set has been developed to facilitate this. The ultimate benefit will be to show that oncologists use treatments proved to be of value in clinical trials to the benefit of patients, and that the best outcomes reported in the literature are achieved by all patients with lung cancer.

Peter Simmonds, senior lecturer in medical oncology. 

CRC Wessex Medical Oncology Unit, Southampton General Hospital, Southampton SO16 6YD