Lung cancer: diagnosis and management: summary of updated NICE guidanceBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l1049 (Published 28 March 2019) Cite this as: BMJ 2019;364:l1049
All rapid responses
The NICE Guidance on management of lung cancer sets out the pathway that people who potentially have lung cancer should follow through to diagnosis and treatment . The expected route to this pathway is covered by the guidance on referral for suspected cancer. The best outcomes for lung cancer are among patients with operable disease and these are often those in whom it is an incidental finding; such patients may have a better prognosis than those with symptoms . Overall, patients with an incidental diagnosis of lung cancer may have a better prognosis even if it is not operable .
It is therefore very important that all radiology reports suggesting a possible lung cancer are acted upon. For example, when a report of a chest x ray done for shoulder trauma identifies a suspicious lung lesion after the patient is discharged, then both patient harm and legal action can ensue if the report is ignored. I am aware of several cases where a lung nodule was an incidental finding on a CT; the radiologist advised followup CTs for which there are established guidelines  but the team receiving the report failed to ensure this happened
BMA guidance is that the doctor requesting the test has the responsibility, which may be delegated, to act on investigation results including the conscious decision that action is inappropriate. In the case of lung cancer this may be because of poor performance status or comorbidity. However, in the hurly-burly of clinical life it is not surprising that findings can be overlooked.
Medicolegal reporting has drawn this pattern of events to my attention. I cannot formally collect a series to publish when I receive information in confidence. I am one low-profile clinician doing this kind of work. How many such cases are occurring out there?
1] National Institute for Health and Care Excellence. Lung cancer: diagnosis and management (NICE guideline 122). Updated 2019. https://www.nice.org.uk/guidance/NG122
2] National Institute for Health and Care Excellence. Suspected cancer: recognition and referral (NICE guideline 12). Updated 2017. https://www.nice.org.uk/guidance/NG12.
3] Orrason AW, Sigurdsson MI, Baldvinsson K, et al. Incidental detection by computed tomography is an independent prognostic factor for survival in patients operated for nonsmall cell lung carcinoma. ERJ Open Res 2017; 3: 00106-2016
4] Kocher F, Lunger F, Seeber A et al. Incidental Diagnosis of Asymptomatic Non–Small-Cell Lung Cancer: A Registry-Based Analysis Clinical Lung Cancer , 2016; 17:, 62 - 67.
5} Callister MEJ, Baldwin DR, Akram AR, et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules Thorax 2015;70 :ii1–ii54.
Competing interests: No competing interests
We read with interest in the BMJ a guideline for the diagnosis and management of lung cancer, published for the benefit of non-specialists.1 We noted that palliative care, a key component of care for people with life-threatening illness was not mentioned at all. This article by failing to even mention that palliative care should be considered is misleading by default to general practitioners for whom it is stated to be relevant. There are established best practice guidelines that recommend palliative care provision by primary care teams with access to specialist advice even while on oncology treatment.2,3 In metastatic non-small cell lung cancer early palliative care significantly improves patient’s mood, quality of life, health care utilisation and survival.4-6 Primary care professionals can play a crucial role in providing early palliative care in the community to the benefit of many. Let’s encourage them to provide this in the guidance they get.7
1. Maconachie R, Mercer T, Navani N, McVeigh G; Guideline Committee.Lung cancer: diagnosis and management: summary of updated NICE guidance BMJ. 2019;364:l1049. doi: 10.1136/bmj.l1049.
2. Ferrell BR, Temel JS, Temin S, et al. Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2017;35:96-112. Epub 2016 Oct 28.
3. Cancer Service Guidance – Improving Supportive and Palliative Care for Adults with Cancer https://www.nice.org.uk/guidance/csg4
4. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med2010;363:733-42. doi:10.1056/NEJMoa1000678 pmid:20818875.
5. Irwin KE, Greer JA, Khatib J, et al. Early palliative care and metastatic non-small cell lung cancer: potential mechanisms of prolonged survival. Chron Respir Dis. 2013;10:35-47. doi: 10.1177/1479972312471549.
6. Temel JS, Greer JA, El-Jawahri A, et al. Effects of early integrated palliative care in patients with lung and GI cancer: a randomized clinical trial. J Clin Oncol. 2017;35:834-41. doi: 10.1200/JCO.2016.70.5046. Epub 2016 Dec 28.
7. Murray SA, Kendall M, Mitchell G et al. Palliative care from diagnosis to death. BMJ. 2017 Feb 27;356:j878. doi: 10.1136/bmj.j878.
Competing interests: No competing interests