Improving Outcomes in Lung Cancer , the third in the series The three linked publications, The Manual , The Research Evidence , and a four-page summary of the main recommendations for GPs and primary healthcare teams, are available free via the NHS response line (0541-555455).
The practical recommendations in the guidance are based on the findings of systematic reviews of the effectiveness of each aspect of lung cancer management, from prevent ion to palliative care, and are summarised in the latest edition of Effective Health Care .
2 Lung cancer is the third most common cause of death in the UK. The disease progresses rapidly and the prognosis is usually poor: around 80 per cent of patients die within a year of diagnosis, and screening does not appear to improve outcomes. The guidance therefore concentrates on prevention and palliative care. Although radical treatment, particularly surgery, can lead to long-term survival, it is only appropriate for a few patients.
Since cigarette smoking accounts for around 90 per cent of deaths from lung cancer, action against smoking should be the primary focus of efforts to improve outcomes. There is good evidence that interventions at national and local levels to help people stop smoking can be highly cost-effective.
Effective interventions are summarised in the most recent issue of Effectiveness Matters (available from the NHS Centre for Reviews and Dissemination).
Significant changes in the structure of lung cancer services in many areas will be needed to implement the recommendations in the guidance. Specialist multiprofessional teams are to be established, to which all patients with suspected lung cancer will be referred. This can be expected to lead to more appropriate treatment and better co-ordination of care.
The choice of treatment depends on the patient's fitness and on whether the tumour is classified as small cell (around 20 per cent of patients) or non-small cell lung cancer; decisions should not be based on the patient's age. Specialist management is likely to mean that more patients will receive an accurate histological diagnosis. High-tech diagnostic methods and imaging systems are not usually necessary.
Since surgery offers the hope of cure, people with tumours that can be completely removed should be identified.
Regrettably, the long-term survival rate in England is low, around 27 per cent at five years, mainly because the cancer is often quite far advanced by the time it is detected. It is important that the tumour stage should be established before surgery so that the number of patients subjected to unsuccessful operations - with the morbidity and waste this entails - is minimised.
Patients with early non-small cell lung cancer, for whom surgery is inappropriate, can be treated with radical radiotherapy. A key recommendation is that these patients are offered CHART (continuous hyperfractionated accelerated radiation therapy) because it reduces mortality significantly in comparison with conventional radiotherapy, and it is cost-effective. Since CHART involves treatment three times daily for 12 consecutive days, radiotherapy needs to be available throughout the weekend.
Chemotherapy is an appropriate first-line treatment for patients with small-cell lung cancer, but requires further evaluation in the treatment of those with non-small cell disease. The ongoing Big Lung Trial will assess this aspect of treatment.
Cancer patients' most common complaint is that they are given too little information about diagnosis and treatment; such information has been found to reduce anxiety, even when the news is bad. In terms of life expectancy, some of the most effective forms of treatment can cause severe adverse effects, and patients should be given accurate information about the anticipated effects of treatment options to enable them to make informed choices about their care. While some patients place great value on the hope of increased survival time, others are more concerned about the quality of their remaining life.
Providing information to patients before treatment has benefits in terms of reducing anxiety, and psycho-educational interventions have been shown to reduce some of the adverse effects of treatment.
Palliative care should be an integral part of management from the time of diagnosis to optimise control of the disease's symptoms. The guidance recommends that specialist lung cancer teams should include both palliative care specialists and nurses who can offer psychosocial support for patients and carers. These teams should work closely with palliative care teams.
Nurse co-ordinators can improve patients' access to appropriate services, preventing uncoordinated home visits, reducing inpatient days and thereby reducing costs.
Probably the most common, disabling and intractable symptom of lung cancer is breathlessness. Although psycho-educational interventions provided by nurses have proved effective in randomised controlled trials, such interventions are, as yet, rarely offered; more nurse specialists will have to be trained to meet this need. There is no reliable evidence of effectiveness for most of the interventions currently used for breathlessness, and home care teams (which are not likely to include lung cancer specialists) may not be able to offer effective help. For some patients, surgical and other invasive interventions are necessary; these should be provided by specialists.
Effective pain relief can be achieved for 80-90 per cent of patients with cancer. However, despite the availability of effective methods of pain control, there is evidence that clinicians frequently fail to recognise that pain is being inadequately managed in patients with advanced lung cancer.
The key recommendations of the new lung cancer guidance are outlined in the box opposite. While the guidance does not propose radical changes in treatment, it does recommend more specialised management, which has implications for the organisation of services. Care management by teams specialising in lung cancer will ensure that many more patients receive optimal treatment.
The guidance proposes a profound shift in emphasis, away from a focus on radical treatment and its concern with survival to an emphasis on the quality of the patient's remaining life. Lung cancer is best prevented, but for those who do develop the disease, palliative care is likely to be essential.
Prevention Action against smoking should be the primary focus of efforts to improve outcomes in lung cancer. Heath professionals should be trained in the use of effective interventions and encouraged to offer them.
Patients with suspected lung cancer should be assessed by a local specialist lung cancer team. Management of care should rest with the team. Patients should have rapid access to appropriate team members throughout.
Palliative care should be integral from the outset, provided by a multiprofessional team with close links to the specialist lung cancer team, sharing at least one member in common.
Effort should be made to identify the minority of patients who would benefit from surgery. Detailed information on cancer type and stage must be obtained before surgery to avoid unnecessary intervention.
CHART radiotherapy Systems should be established to allow CHART to be offered to appropriate patients, every day of the week.
Chemotherapy New chemotherapy drugs should not usually be used until they have been subjected to rigorous trials to evaluate clinical and cost effectiveness and effects on quality of life.
1 National Cancer Guidance Group. Improving Outcomes in Lung Cancer: the manual. Improving Outcomes in Lung Cancer: the research evidence. NHS Executive, 1998.
2 Management of lung cancer. Effective Health Care June 1998; 4(3).
3 Smoking cessation: what the health service can do. Effectiveness Matters March 1998; 3(1).
Effective Health Care bulletins provide NHS decision makers with information on the effectiveness and cost-effectiveness of interventions and the delivery and organisation of healthcare. The Department of Health funds a limited number of bulletins for distribution within the NHS. Enquiries should be addressed to: NHS Centre for Reviews & Dissemination, York University, York YO1 5DD; tel: 01904 433634; fax: 01904 433661; E-mail: email@example.com