Resumo do NICE
As recomendações neste tópico do Best Practice são baseadas em diretrizes internacionais autorizadas, complementadas por evidências e opiniões de especialistas relevantes para a prática recentes. Para seu maior benefício resumimos abaixo as principais recomendações das diretrizes do NICE relevantes.
Principais recomendações do NICE sobre diagnóstico
Refer people using a suspected cancer pathway referral for lung cancer if they:[85]
Have chest X-ray findings that suggest lung cancer,or
Are aged 40 years and over with unexplained haemoptysis.
Offer an urgent (i.e., to be done within 2 weeks) chest X-ray to people aged 40 years and over if they have 2 or more of the following unexplained symptoms, or they have ever smoked and have 1 or more of the following unexplained symptoms:[85]
Cough
Fatigue
Shortness of breath
Chest pain
Weight loss
Appetite loss.
Consider an urgent chest X-ray for people aged 40 years and over with any of the following:[85]
Persistent or recurrent chest infection
Finger clubbing
Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
Chest signs consistent with lung cancer
Thrombocytosis.
Unexplained weight loss and unexplained appetite loss may be symptoms of lung cancer. Assess people with either symptom for additional features of cancer and offer urgent investigation or a suspected cancer pathway referral.[85]
Deep vein thrombosis is associated with several cancers including lung cancer. Assess people with deep vein thrombosis for additional features of cancer and consider urgent investigation or a suspected cancer pathway referral.[85]
Refer all people with suspected lung cancer to a lung cancer multidisciplinary team.[86]
Diagnostic and staging investigations
Investigations for small-cell lung cancer should be chosen based on which will give the most information about diagnosis and staging with the least risk to the person, and whether the person is well enough for treatment with curative intent:[86]
A contrast-enhanced chest CT scan (inclusive of the liver, adrenals and lower neck) should be offered for diagnosis and staging (before any biopsy procedure)
Positron-emission tomography CT (PET-CT) should be offered to:
All people with lung cancer who could potentially have treatment with curative intent, before treatment. PET-CT should be offered as the preferred first test after CT with low probability of nodal malignancy for these people
People with suspected lung cancer and enlarged intrathoracic lymph nodes on CT, who could potentially have treatment with curative intent
Biopsies may be taken (from the primary lesion or from lymph nodes or other lesions) if this will affect treatment and does not pose unacceptable risk to the person
Biopsy or further imaging should be used to confirm the presence of isolated distant metastases/synchronous tumours, if considering treatment with curative intent.
Other investigations may include:[86]
Flexible bronchoscopy (e.g., for people with central lesions on CT if nodal staging does not influence treatment)
Sputum cytology (only in people with centrally placed nodules/masses who decline or cannot tolerate bronchoscopy or other invasive tests)
Endobronchial ultrasound-guided transbronchial needle aspiration (e.g., for biopsy of paratracheal and peri-bronchial intra-parenchymal lung lesions) and/or endoscopic ultrasound-guided fine-needle aspiration (e.g., for biopsy of suspicious intrathoracic nodes seen on imaging where nodal status would affect treatment)
Image-guided biopsy (e.g., for people with peripheral lung lesions)
Surgical assessment (e.g., may be necessary to assess mediastinal/chest wall invasion, or for mediastinal staging when there is high suspicion of nodal malignancy [which would affect treatment] but other investigations have been negative)
Other imaging:
Ultrasound (e.g., for assessing mediastinal/chest wall invasion, where CT alone may not be reliable)
MRI (e.g., for assessing disease extent in people with superior sulcus tumours)
Head CT/MRI (e.g., when clinical features suggest intracranial pathology)
X-ray (e.g., first test for people with localised features of bone metastasis)
Bone scintigraphy or MRI (e.g., for people with localised features of bone metastasis when X-ray is negative/inconclusive; bone scintigraphy should be avoided when PET-CT has not shown bone metastases).
Link para a orientação do NICE
Lung cancer: diagnosis and management (NG122) March 2024. https://www.nice.org.uk/guidance/ng122
Suspected cancer: recognition and referral (NG12) October 2023. https://www.nice.org.uk/guidance/ng12
Principais recomendações do NICE sobre tratamento
Advise people to stop smoking as soon as the diagnosis of lung cancer is suspected and tell them why this is important.[86]
Offer nicotine replacement therapy and other therapies to help people stop smoking in line with the NICE guideline Tobacco: preventing uptake, promoting quitting and treating dependence (NG209). Surgery should not be postponed to allow people to stop smoking but they should be advised that smoking increases the risk of pulmonary complications after lung cancer surgery.[86]
People should have access to a lung cancer nurse specialist at all stages of care.[86]
Treatment for small-cell lung cancer (SCLC) should be provided without undue delay (whether treating with curative intent or for symptomatic relief).[86]
Assessment by a thoracic oncologist should be arranged to take place within 1 week of the decision to recommend treatment.[86]
Offer to discuss end-of-life care with the person when appropriate. Wherever possible, avoid leaving this discussion until the terminal stages of the illness. Identify and refer people who may benefit from specialist palliative care services without delay.[86]
First-line treatment for limited-stage disease (broadly corresponding to T1-4, N0-3, M0)
Cisplatin-based combination chemotherapy (4 to 6 cycles), or in some cases (e.g., impaired renal function, poor performance status [WHO 2 or more], significant comorbidity) carboplatin-based combination chemotherapy, should be offered to people with limited-stage disease SCLC.[86]
Twice-daily concurrent radiotherapy should be offered to people with WHO 0 or 1 who present with disease that can be encompassed in a radical thoracic radiotherapy volume. Once-daily radiotherapy should be offered if the person declines or is unable to have twice-daily radiotherapy. Sequential radiotherapy should be offered to people who are not well enough for concurrent chemoradiotherapy but who respond to chemotherapy.[86]
Prophylactic cranial irradiation should be offered to people with WHO 2 or less, if their disease has not progressed on first-line treatment.[86]
Surgery
Surgery should be considered for people with early-stage SCLC (T1-2a, N0, M0).[86]
First-line treatment for extensive-stage disease (broadly corresponding to T1-4, N0-3, M1a/b – including cerebral metastases)
Platinum-based combination chemotherapy should be offered to people with extensive-stage disease SCLC if they are fit enough.[86]
The following treatment should be considered:[86]
Thoracic radiotherapy with prophylactic cranial irradiation for people who have had partial or complete response to chemotherapy within the thorax and at distant sites
Prophylactic cranial irradiation for people with WHO 2 or less, if their disease has responded to first-line treatment.
Maintenance treatment
Maintenance treatment for SCLC should only be offered in the context of a clinical trial.[86]
Second-line treatment for disease relapse after first-line treatment
Assessment by a thoracic oncologist should be offered to people with SCLC that has relapsed after first-line treatment.[86]
People whose disease has not responded to first-line treatment should be informed that there is very limited evidence that second-line chemotherapy will be of benefit.[86]
An anthracycline-containing regimen or further treatment with a platinum-based regimen should be offered if chemotherapy is suitable for the person.[86]
Oral topotecan is a second-line option only if re-treatment with the first-line regimen is not appropriate and a combination of cyclophosphamide, doxorubicin and vincristine is contraindicated.[87]
Radiotherapy for palliation of local symptoms should be offered.[86]
Follow-up
An initial specialist follow-up appointment should be offered to all people with lung cancer within 6 weeks of completing treatment, followed by regular appointments.[86]
Protocol-driven follow-up led by a lung cancer clinical nurse specialist should be offered as an option for people with a life expectancy of more than 3 months.[86]
© NICE (2009) (2023) (2024) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights . All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Link para a orientação do NICE
Lung cancer: diagnosis and management (NG122) March 2024. https://www.nice.org.uk/guidance/ng122
Topotecan for the treatment of relapsed small-cell lung cancer (TA184) November 2009. https://www.nice.org.uk/guidance/ta184
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