The American College of Chest Physicians (ACCP) third edition of evidence-based lung cancer guidelines, Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, recommends offering low-dose computed tomography (LDCT) scanning for lung cancer screening to people with a significant risk of lung cancer due to age and smoking history.
Published as a special supplement to the May issue of CHEST, ACCP’s peer-reviewed journal, the guidelines cite evidence to show lung cancer screening, through a structured and specific protocol, can reduce lung cancer deaths among individuals who are at elevated risk of developing lung cancer. The guidelines also document the advances made over the past 5 years in the treatment of tobacco use, including the benefits of tobacco cessation programs, in patients with lung cancer. The most effective deterrent to acquiring lung cancer is avoidance of tobacco products.
“Our new lung cancer guidelines take into account the many advances and new information in the field by providing comprehensive and nuanced recommendations related to prevention, screening, diagnosis, staging, and medical and surgical treatments,” said Guideline Panel Chair, W. Michael Alberts, MD, MBA, FCCP, Moffitt Cancer Center, Tampa, FL. “It also showcases the importance of multidisciplinary, team-based care when it comes to effective lung cancer treatment—collaborative decisions based on collective knowledge provide the most comprehensive patient-focused care.”
For individuals at elevated risk of developing lung cancer, the guidelines recommend offering LDCT scanning to screen for lung cancer in the context of a structured, organized screening program. The recommendation is based on a systematic review of the data that shows an important reduction in deaths from lung cancer when screening is done in an organized program. This is a clear change from the prior edition of the guidelines released in 2007, when such evidence was not available.
Lung cancer screening is a complex interplay of an individual’s risk and many other key factors, including how LDCT scanning is performed and interpreted by the team. This must then be coupled with careful judgment that minimizes interventions to those that are necessary and education to appropriately balance concerns associated with lung cancer, radiation, and observation of incidental nodules. The guidelines call for the establishment of a registry designed to help address the large number of unanswered questions that arise as screening is implemented, as well as to clarify frequent misconceptions around lung cancer screening among patients and physicians. Additionally, the guidelines call for establishment of quality metrics so that benefits are optimized, and harm is kept low.
“Lung cancer screening offers a potential benefit for select individuals, but it is not a substitute for stopping smoking,” said Frank Detterbeck, MD, FCCP, Yale University, New Haven, CT, and Vice-Chair of the Guidelines Panel. “However, screening is not a scan, it is a process. We have much to learn as we embark upon implementation of screening. Education on screening is the key to overcoming misconceptions and misguided fears. The guidelines include recommendations that help the patient and physician with the decision process. It provides a structure that gives a clearer interpretation of what we know and what we can only speculate.”
Treatment of lung cancer is progressing rapidly, with significant advances in all modalities, including surgery, radiation, and chemotherapy. Treatment procedures detailed in the guidelines include the benefits of minimally invasive surgery whenever possible, as well as the benefit of treatment at specialized centers. Today, patients with limited lung function also have treatment options such as stereotactic body radiosurgery, which is similar to using a GPS system to deliver a laser-accurate strike to a tumor. Molecular-based targeted chemotherapy can also shut down the cellular engine driving a tumor’s growth as dramatically as flipping a switch. The guidelines also make it clear that a sophisticated approach to symptom control and palliative care can markedly improve both quality and quantity of life for individuals with lung cancer.
However, the data presented in the guidelines also underscore the importance of an integrated collaborative team of individuals, each with lung cancer expertise within his or her own specialty.
“All stages of non-small cell lung cancer involve complex factors,” said Darcy Marciniuk, MD, FCCP, Royal University Hospital, Saskatoon, Saskatchewan, and ACCP President. “In the guidelines, we highlight these factors throughout all stages, including symptom management, special treatment, complementary or alternative therapies, and end-of-life care.”
Treatment of Tobacco Use
An ounce of prevention is still best; and the science behind treatment of tobacco dependency has matured tremendously. This edition of the guidelines outlines how to select the right interventions for someone who smokes and improve the rate of successful abstinence from smoking.
“Smoking is a difficult addiction to overcome; however, significant advances have increased our understanding of the physiological and biological changes that make this chronic medical condition so challenging. Today, we have multiple treatment options to help these patients,” said Frank Leone, MD, FCCP, University of Pennsylvania, Philadelphia, PA, and topic editor of “Treatment of Tobacco Use in Lung Cancer,” in Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. “The guidelines include a detailed summary of the scientific basis and management strategies for an up-to-date, sophisticated, and evidence-based treatment program for tobacco use.”
Symptom Management and Palliation
For patients with advanced lung cancer, a major concern is palliation, easing the severity of pain and symptoms. In the past, the approach to palliative care was largely empiric, but as summarized in the guidelines, a large body of research has led to the development of a more formal evidence-based process. Many tools are available that provide an effective structure for both symptom management and for facilitating the process of end-of-life care. The data also demonstrate that early inclusion of a palliative care team in the management of advanced lung cancer has meaningful quality of life benefits for the patient.
"The scope of this chapter is very large,” said Michael J. Simoff, MD, FCCP, Henry Ford Hospital, Detroit, MI, and topic editor of “Symptom Management in Patients With Lung Cancer,” in Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. “Few classic double-blind, randomized studies exist to give guidance in many of the areas covered in the chapter. Experts in many specialties were brought together to ask the questions necessary and get the best answers possible from the literature to guide physician management of the symptoms encountered in lung cancer patients."
The guidelines also devote attention to complementary therapies and integrative medicine in lung cancer. This includes interventions such as acupuncture, nutrition, and mind-body therapies. The guidelines outline which treatments and situations are scientifically supported for integration with standard treatments for lung cancer.