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Developing and assessing treatment algorithms for the management of lung cancer in NSW

Research updates
Issue 5, September 2010
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The Cancer Epidemiology Research Unit of the Cancer Council NSW was commissioned by the Cancer Institute NSW to develop clinically relevant algorithms for the treatment of lung cancer in NSW. This initiative arose from the Cancer Institute NSW Oncology Group (NSWOG) for lung cancer which identified this activity as its highest priority area.

Developing and assessing treatment algorithms for the management of lung cancer in NSW

The aim was to develop and assess the use of algorithms describing lung cancer in NSW. Members of the NSWOG lung were to assist in the development process by identifying the appropriate management of each stage of non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC).

At the workshop attended by members of the NSWOG Lung Group in April 2010, the target audience for the algorithms was defined as health care professionals involved in diagnosing and managing patients with lung cancer. This includes general practitioners, nurses and care coordinators as well as respiratory physicians and lung cancer specialists.

Aims

The specific aims of the project were to:

  1. Collect and review treatment algorithms for lung cancer currently in use in NSW
  2. Develop consensus treatment algorithms
  3. Review the evidence supporting the consensus algorithms for the treatment of lung cancer in NSW
  4. Formulate final treatment algorithms
  5. Develop a simple clinical tool based on these algorithms

Methods

  1. Collect and review treatment algorithms for lung cancer currently in use in NSW
  2. Develop consensus treatment algorithms
  3. Review the evidence supporting the consensus algorithms for the treatment of lung cancer in NSW
  4. Formulate final treatment algorithms
  5. Develop a simple clinical tool based on these algorithms

Results

Management of non-small cell lung cancer - Workshop recommendations 21 April 2010

Clinical Stage I (TIN0, T2N0)

Flowchart showing the treatment decisions for Clinical Stage I lung cancer

Clinical Stage II (T1a,bN1, T2aN1, T3N0)

Flowchart showing the treatment decisions for Clinical Stage II lung cancer

Clinical Stage IIIA (T1-3N2, T3N1, T4N0-1)

Flowchart showing the treatment decisions for Clinical Stage IIIA lung cancer

Clinical Stage IIIB (T1-3N3, T4N2-3)

Flowchart showing the treatment decisions for Clinical Stage IIIB lung cancer

Clinical Stage IV (M1)

Flowchart showing the treatment decisions for Clinical Stage IV lung cancer

Management recommendations for non-small cell lung cancer by stage

Clinical Stage (TNM 7th Ed.) Management
(Follow chemotherapy and radiotherapy protocols described in EviQ) 		Supportive Care
I-IV Pre-Treatment Assessment:
  1. Confirm stage
  2. Assess patient's fitness for treatment (MDT assessment: Surgeon and Respiratory Physician to assess fitness for surgery, Medical Oncologist for chemotherapy and Radiation Oncologist for radiotherapy)
  3. Stabilise other conditions first
I
(T1N0, T2N0)
  1. Surgery (ECOG 0-2)
  2. Definitive RT (ECOG 0-2)
  3. Palliative RT (ECOG 3-4, symptomatic)
  4. Supportive care with symptom monitoring (ECOG 3-4, asymptomatic)
  • Lung cancer nurse
  • Access to psychosocial and spiritual support
  • Look for support in community setting
  • GPs to play important role throughout (monitor for onset of symptoms)
II
(T1a,bN1, T2aN1, T3N0)
  1. Surgery + adjuvant chemotherapy if N1. Consider chemotherapy if N0# (ECOG 0-2)
  2. Definitive ChemoRT - concurrent or sequential  (ECOG 0-2)
  3. Definitive RT alone (ECOG 0-2)
  4. Palliative RT (ECOG 3-4, symptomatic)
  5. Supportive care with symptom monitoring (ECOG 3-4, asymptomatic)
# limited evidence for T3N0		 Same as Stage I
IIIA
(T1-3N2,
T3N1,
T4N0-1)

MDT assessment prior to any treatment decisions
Treatment based on investigative findings:

CT suspicious, PET +ve, non bulky nodes, single station N2:

  1. Induction chemo then surgery +/- RT (ECOG 0-2)
  2. Surgery plus adjuvant chemo +/- RT (ECOG 0-2)
  3. Definitive ChemoRT -concurrent or sequential (ECOG 0-2)
  4. Definitive RT (ECOG 0-2, unfit for chemotherapy)
  5. Palliative RT (ECOG 3-4, symptomatic)
  6. Supportive care with symptom monitoring (ECOG 3-4, asymptomatic)

CT suspicious, PET+ve, bulky nodes or multiple nodal levels:

  1. Defintive ChemoRT-concurrent or sequential (ECOG 0-2)
  2. Definitive RT (ECOG 0-2, unfit for chemotherapy)
  3. Consider Palliative RT if definitive RT contraindicated (ECOG 0-2, chest symptoms)
  4. Palliative Chemotherapy if RT contraindicated (ECOG 0-2), no chest symptoms)
  5. Palliative RT (ECOG 3-4, symptomatic)
  6. Supportive care with symptom monitoring (ECOG 3-4, asymptomatic)
Pathological Stage IIIA (Positive nodes found at surgery)
consider adjuvant chemotherapy and adjuvant RT

Same as Stage I plus

  • Early involvement of palliative care services

IIIB
(T1-3N3,
T4N2-3)
  1. Definitive ChemoRT -concurrent or sequential (ECOG 0-2)
  2. Definitive RT (ECOG 0-2, unfit for chemotherapy)
  3. Consider Palliative RT if definitive RT contraindicated (ECOG 0-2, chest symptoms)
  4. Palliative Chemotherapy  if RT contraindicated (ECOG 0-2), no chest symptoms)
  5. Palliative RT (ECOG 3-4, symptomatic)
  6. Supportive care with symptom monitoring (ECOG 3-4, asymptomatic)
 Same as Stage IIIA
IV
(M1)

Active treatment should begin with appropriate supportive care
Treatment based on symptoms (local or systemic)

Local Symptoms:

  • Palliative RT
  • Laser therapy (airway obstruction)
  • Stent (airway obstruction)
  • Drainage of pleural effusion +/- pleurodesis
Systemic Symptoms:
Brain metastases
  • Surgery or  stereotactic RT plus whole brain RT (solitary brain mets, ECOG 0-2)
  • Whole brain RT (multiple brain mets, ECOG 0-2)
  • Supportive care  (ECOG 3-4)
Bone metastases
  • RT for pain
  • Fixation to prevent fracture
  • Supportive care (ECOG 3-4)
Other metastases
  • Chemotherapy +/- biologic agents
  • Supportive care  (ECOG 3-4)
 Same as Stage IIIA
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