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Lung cancer overview

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Lung cancer HAI

About

What is covered

This pathway covers the diagnosis and treatment of lung cancer.
There are more than 39,000 new cases of lung cancer in the UK each year and more than 35,000 people die from the condition. Only about 5.5% of lung cancers are currently cured. Although the cure rate is rising slowly, the rate of improvement has been slower than for other common cancers. Outcomes in the UK are worse than those in some European countries and North America. There is also evidence that outcomes vary within the UK, which – among other factors – may be explained by variations in the standard of care.
This pathway provides recommendations for good practice in the diagnosis and treatment of non-small-cell and small-cell lung cancer.

Updates

Updates to this pathway

17 October 2014 Minor maintenance updates.
10 September 2014 Minor maintenance updates.
22 April 2014 'Afatinib for treating epidermal growth factor receptor mutation-positive locally advanced or metastatic non-small-cell lung cancer' (NICE technology appraisal guidance 310) and 'Pemetrexed maintenance treatment following induction therapy with pemetrexed and cisplatin for non-squamous non-small-cell lung cancer' (NICE technology appraisal guidance 309) added to the treatment for non-small-cell lung cancer path.
26 November 2013 'Microwave ablation for treating primary lung cancer and metastases in the lung' (NICE interventional procedure guidance 469) added to 'first-line and maintenance treatment' and 'second-line treatment' in the path treatment for small-cell lung cancer and to 'ablation procedures for primary and secondary lung cancers' in the path treatment for non-small-cell lung cancer.
25 September 2013 'Crizotinib for previously treated non-small-cell lung cancer associated with an anaplastic lymphoma kinase fusion gene' (NICE technology appraisal guidance 296) added to the treatment for non-small-cell lung cancer path. A costing statement was also added for this guidance and minor maintenance updates made.
13 August 2013' EGFR TK mutation testing in adults with locally advanced or metastatic non-small-cell lung cancer' (NICE diagnostics guidance 9) added to the further tests before treatment with curative intent path and minor maintenance updates.
16 July 2013 'SonoVue for contrast-enhanced ultrasound imaging of the liver' (NICE diagnostics guidance 5) added to the diagnosis and staging of lung cancer path.
3 April 2012 The quality statement on palliative interventions was removed from the treatment for small-cell lung cancer path.
27 June 2012 'Erlotinib for the first-line treatment of locally advanced or metastatic EGFR-TK mutation-positive non-small-cell lung cancer' (NICE technology appraisal guidance 258) added to the treatment for non-small-cell lung cancer path. Information for the public, updated lung cancer audit support and a costing statement for this guidance also added.
17 August 2012 A recommendation on referral was updated to reflect the requirement for immediate referral for superior vena cava obstruction and stridor.
23 October 2012 'Denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours' (NICE technology appraisal guidance 265) added to the supportive and palliative care for lung cancer path. Information for the public, audit support and costing for this guidance also added.
30 October 2012 Minor maintenance updates.
20 December 2012 Details about the patient access scheme for 'Erlotinib for the treatment of non-small-cell lung cancer' (NICE technology appraisal guidance 162) added to the treatment for non-small cell lung cancer path.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

The diagnosis and treatment of lung cancer

What is covered

This pathway covers the diagnosis and treatment of lung cancer.
There are more than 39,000 new cases of lung cancer in the UK each year and more than 35,000 people die from the condition. Only about 5.5% of lung cancers are currently cured. Although the cure rate is rising slowly, the rate of improvement has been slower than for other common cancers. Outcomes in the UK are worse than those in some European countries and North America. There is also evidence that outcomes vary within the UK, which – among other factors – may be explained by variations in the standard of care.
This pathway provides recommendations for good practice in the diagnosis and treatment of non-small-cell and small-cell lung cancer.

Updates

Updates to this pathway

17 October 2014 Minor maintenance updates.
10 September 2014 Minor maintenance updates.
22 April 2014 'Afatinib for treating epidermal growth factor receptor mutation-positive locally advanced or metastatic non-small-cell lung cancer' (NICE technology appraisal guidance 310) and 'Pemetrexed maintenance treatment following induction therapy with pemetrexed and cisplatin for non-squamous non-small-cell lung cancer' (NICE technology appraisal guidance 309) added to the treatment for non-small-cell lung cancer path.
26 November 2013 'Microwave ablation for treating primary lung cancer and metastases in the lung' (NICE interventional procedure guidance 469) added to 'first-line and maintenance treatment' and 'second-line treatment' in the path treatment for small-cell lung cancer and to 'ablation procedures for primary and secondary lung cancers' in the path treatment for non-small-cell lung cancer.
25 September 2013 'Crizotinib for previously treated non-small-cell lung cancer associated with an anaplastic lymphoma kinase fusion gene' (NICE technology appraisal guidance 296) added to the treatment for non-small-cell lung cancer path. A costing statement was also added for this guidance and minor maintenance updates made.
13 August 2013' EGFR TK mutation testing in adults with locally advanced or metastatic non-small-cell lung cancer' (NICE diagnostics guidance 9) added to the further tests before treatment with curative intent path and minor maintenance updates.
16 July 2013 'SonoVue for contrast-enhanced ultrasound imaging of the liver' (NICE diagnostics guidance 5) added to the diagnosis and staging of lung cancer path.
3 April 2012 The quality statement on palliative interventions was removed from the treatment for small-cell lung cancer path.
27 June 2012 'Erlotinib for the first-line treatment of locally advanced or metastatic EGFR-TK mutation-positive non-small-cell lung cancer' (NICE technology appraisal guidance 258) added to the treatment for non-small-cell lung cancer path. Information for the public, updated lung cancer audit support and a costing statement for this guidance also added.
17 August 2012 A recommendation on referral was updated to reflect the requirement for immediate referral for superior vena cava obstruction and stridor.
23 October 2012 'Denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours' (NICE technology appraisal guidance 265) added to the supportive and palliative care for lung cancer path. Information for the public, audit support and costing for this guidance also added.
30 October 2012 Minor maintenance updates.
20 December 2012 Details about the patient access scheme for 'Erlotinib for the treatment of non-small-cell lung cancer' (NICE technology appraisal guidance 162) added to the treatment for non-small cell lung cancer path.

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Lung cancer. NICE clinical guideline 121 (2011)
Gefitinib for the first-line treatment of non-small-cell lung cancer. NICE technology appraisal guidance 192 (2010)
Pemetrexed for the maintenance treatment of non-small-cell lung cancer. NICE technology appraisal guidance 190 (2010)
Topotecan for the treatment of small-cell lung cancer. NICE technology appraisal guidance 184 (2009)
Pemetrexed for the first-line treatment of non-small-cell lung cancer. NICE technology appraisal guidance 181 (2009)
Erlotinib for the treatment of non-small-cell lung cancer. NICE technology appraisal guidance 162 (2008)
Pemetrexed for the treatment of non-small-cell lung cancer. NICE technology appraisal guidance 124 (2007)
Percutaneous radiofrequency ablation for primary and secondary lung cancers. NICE interventional procedure guidance 372 (2010)
Cryotherapy for endobronchial obstruction. NICE interventional procedure guidance 142 (2005)
Photodynamic therapy for localised inoperable endobronchial cancer. NICE interventional procedure guidance 137 (2005)
Photodynamic therapy for advanced bronchial carcinoma. NICE interventional procedure guidance 87 (2004)
Stent placement for vena caval obstruction. NICE interventional procedure guidance 79 (2004)

Quality standards

Quality statements

Public awareness

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People are made aware of the symptoms and signs of lung cancer through local coordinated public awareness campaigns that result in early presentation.

Quality measure

Structure
Evidence of local arrangements to ensure that people are made aware of the symptoms and signs of lung cancer through local coordinated public awareness campaigns that result in early presentation.
Process
Proportion of people newly diagnosed with lung cancer who were identified as a result of a local public awareness campaign.
Numerator – the number of people in the denominator who were identified as a result of a local public awareness campaign.
Denominator – the number of people newly diagnosed with lung cancer who presented with at least one symptom suggesting lung cancer.
Outcome
a) People with a new diagnosis of lung cancer whose first contact with secondary care for their cancer is an emergency hospital visit or admission.
b) 3-month and 1-year survival rates from diagnosis.
c) Public awareness of symptoms and signs of lung cancer.
d) Stage at diagnosis.

Description of what the quality statement means for each audience

Service providers ensure that services are in place to support people to be made aware of the symptoms and signs of lung cancer through local coordinated public awareness campaigns that result in early presentation.
Healthcare professionals support and participate in local coordinated public awareness campaigns to make people aware of the symptoms and signs of lung cancer and that result in early presentation.
Commissioners ensure they commission local coordinated public awareness campaigns to make people aware of the symptoms and signs of lung cancer and that result in early presentation.
People are made aware of the symptoms and signs of lung cancer through local public awareness information and activities, and see a healthcare professional if they experience symptoms of lung cancer.

Source clinical guideline references

NICE clinical guideline 121 recommendation 1.1.1 (key priority for implementation).
NICE clinical guideline 27 recommendation 1.1.15.

Data source

Structure
Local data collection.
Process
Local data collection.
Outcome
a) Data fields necessary for the calculation of the number of lung cancer patients who were referred to a consultant following accident and emergency attendance are available in the National Cancer Outcomes and Services dataset (in development), which is available from the National Cancer Intelligence Network.
National Cancer Intelligence Network work on 'routes to diagnosis' produces reports on the proportion of lung cancer cases whose first presentation to secondary care was via an emergency admission.
b) Health and Social Care Information Centre National Lung Cancer Data Audit collects data on the proportion of patients submitted to the audit surviving to 3 months and 1 year after diagnosis.
1-year survival from lung cancer is also an improvement area within the NHS Outcomes Framework 2012/13 (1.4v).
c) Local data collection. The lung cancer awareness measure is available from Cancer Research UK.
d) Local data collection.

Definitions

Symptoms and signs suggesting lung cancer include the following:
  • haemoptysis (in particular persistent haemoptysis in smokers/ex-smokers older than 40 years)
  • unexplained or persistent (that is, lasting more than 3 weeks):
    • cough
    • chest/shoulder pain
    • dyspnoea
    • weight loss
    • chest signs
    • hoarseness
    • finger clubbing
    • features suggesting metastasis from a lung cancer (for example, in brain, bone, liver or skin)
    • cervical/supraclavicular lymphadenopathy
  • signs of superior vena cava obstruction (swelling of the face/neck with fixed elevation of jugular venous pressure)
  • stridor.
Early presentation means a person presents to a healthcare professional soon after they recognise that they fulfil criteria for seeking help, normally within 2 weeks. For example, if they have had a persistent cough for 3 weeks or haemoptysis they should seek help from a healthcare professional within 2 weeks.

Referral for chest X-ray

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People reporting one or more symptoms suggesting lung cancer are referred within 1 week of presentation for a chest X-ray or directly to a chest physician who is a core member of the lung cancer multidisciplinary team.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people reporting one or more symptoms suggesting lung cancer are referred within 1 week of presentation for a chest X-ray or directly to a chest physician who is a core member of the lung cancer multidisciplinary team.
Process
a) Proportion of people reporting one or more symptoms suggesting lung cancer who are referred within 1 week of presentation for a chest X-ray or directly to a chest physician who is a core member of the lung cancer multidisciplinary team.
Numerator – the number of people in the denominator who are referred within 1 week of presentation for a chest X-ray or directly to a chest physician who is a core member of the lung cancer multidisciplinary team.
Denominator – the number of people reporting one or more symptoms suggesting lung cancer.
b) Proportion of people with lung cancer who saw their GP about symptoms suggesting lung cancer no more than twice in the last 6 months before referral for a chest X-ray or directly to a chest physician who is a core member of the lung cancer multidisciplinary team.
Numerator – the number of people in the denominator who saw their GP about symptoms suggesting lung cancer no more than twice in the last 6 months before referral.
Denominator – the number of people with lung cancer referred for a chest X-ray or directly to a chest physician who is a core member of the lung cancer multidisciplinary team.
Outcome
Chest X-ray referral rates in people over 50 years.

Description of what the quality statement means for each audience

Service providers ensure there are systems in place for people reporting one or more symptoms suggesting lung cancer to be referred within 1 week of presentation for a chest X-ray or directly to a chest physician who is a core member of the lung cancer multidisciplinary team.
Healthcare professionals refer people reporting one or more symptoms suggesting lung cancer for a chest X-ray or directly to a chest physician who is a core member of the lung cancer multidisciplinary team within 1 week of presentation.
Commissioners ensure they commission services for people reporting one or more symptoms suggesting lung cancer to be referred within 1 week of presentation for a chest X-ray or directly to a chest physician who is a core member of the lung cancer multidisciplinary team.
People who go to their doctor with symptoms of possible lung cancer are referred for a chest X-ray or directly to a chest physician who is a member of the lung cancer multidisciplinary team within 1 week of presentation.

Source clinical guideline references

NICE clinical guideline 121 recommendations 1.1.2, 1.1.5 and 1.3.31.
NICE clinical guideline 27 recommendations 1.2.3, 1.2.6 and 1.2.14 (key priorities for implementation).

Data source

Structure
Local data collection.
Process
a) Local data collection. Contained in the NICE audit support for lung cancer (NICE clinical guideline 121): access to services and referral, criteria 1 and 4.
b) The Department of Health National Cancer Patient Experience Survey report 2010 (data can be disaggregated for lung cancer) contained information on the proportion of patients who saw their GP no more than twice before referral to hospital.
Outcome
Data fields necessary for the calculation of the number of chest X-rays carried out, disaggregated by general practice, are available in the Information Standards Board for Health and Social Care Diagnostic Imaging Dataset (in development).

Definitions

Symptoms and signs suggesting lung cancer requiring an urgent referral for chest X-ray include the following:
  • haemoptysis
  • unexplained or persistent (that is, lasting more than 3 weeks):
    • cough
    • chest/shoulder pain
    • dyspnoea
    • weight loss
    • chest signs
    • hoarseness
    • finger clubbing
    • features suggesting metastasis from a lung cancer (for example, in brain, bone, liver or skin)
    • cervical/supraclavicular lymphadenopathy.
Symptoms and signs suggesting lung cancer requiring an urgent referral to a member of the lung cancer multidisciplinary team (either directly or while awaiting the result of a chest X-ray) include:
  • persistent haemoptysis in smokers/ex-smokers older than 40 years
  • signs of superior vena cava obstruction (swelling of the face/neck with fixed elevation of jugular venous pressure)
  • stridor.

Chest X-ray report

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People with a chest X-ray result suggesting lung cancer have a copy of the radiologist's report sent to and followed up by the lung cancer multidisciplinary team.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols for people with a chest X-ray result suggesting lung cancer to have a copy of the radiologist's report sent to and followed up by the lung cancer multidisciplinary team.
Process
Proportion of people with a chest X-ray result suggesting lung cancer who have a copy of the radiologist's report sent to and followed up by the lung cancer multidisciplinary team.
Numerator – the number of people in the denominator who have a copy of the radiologist's report sent to and followed up by the lung cancer multidisciplinary team.
Denominator – the number of people with a chest X-ray result suggesting lung cancer.

Description of what the quality statement means for each audience

Service providers ensure there are systems in place for people with a chest X-ray result suggesting lung cancer to have a copy of the radiologist's report sent to and followed up by the lung cancer multidisciplinary team.
Radiologists send a copy of their report to the lung cancer multidisciplinary team for people with a chest X-ray result suggesting lung cancer, which is followed up by the multidisciplinary team.
Commissioners ensure they commission services for people with a chest X-ray result suggesting lung cancer to have a copy of the radiologist's report sent to and followed up by the lung cancer multidisciplinary team.
People with signs of possible lung cancer on a chest X-ray have a copy of their X-ray report sent to and followed up by the lung cancer multidisciplinary team

Source clinical guideline references

NICE clinical guideline 121 recommendation 1.1.6.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

This quality statement does not detract from the principle of responsibility for follow-up resting with the clinician who ordered the test. The statement describes an additional step that is important for picking up incidental chest X-ray findings suggesting lung cancer.

Lung cancer clinical nurse specialist

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People with known or suspected lung cancer have access to a named lung cancer clinical nurse specialist who they can contact between scheduled hospital visits.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with known or suspected lung cancer have access to a named lung cancer clinical nurse specialist who they can contact between scheduled hospital visits.
Process
a) Proportion of people with known or suspected lung cancer who have been given the name and contact number of a lung cancer clinical nurse specialist who they can contact between scheduled hospital visits.
Numerator – the number of people in the denominator who have been given the name and contact number of a lung cancer clinical nurse specialist who they can contact between scheduled hospital visits.
Denominator – the number of people with known or suspected lung cancer.
b) Proportion of people with lung cancer who had a lung cancer clinical nurse specialist present at diagnosis.
Numerator – the number of people in the denominator who had a lung cancer clinical nurse specialist present at diagnosis.
Denominator – the number of people with lung cancer.
c) Proportion of people with lung cancer who have been assessed by a lung cancer clinical nurse specialist.
Numerator – the number of people in the denominator who have been assessed by a lung cancer clinical nurse specialist.
Denominator – the number of people with lung cancer.
Outcome
Patient satisfaction with access to and support from a lung cancer clinical nurse specialist.

Description of what the quality statement means for each audience

Service providers ensure there are systems in place for people with known or suspected lung cancer to have access to a named lung cancer clinical nurse specialist who they can contact between scheduled hospital visits.
Healthcare professionals ensure people with known or suspected lung cancer have access to a named lung cancer clinical nurse specialist who they can contact between scheduled hospital visits.
Commissioners ensure they commission services for people with known or suspected lung cancer to have access to a named lung cancer clinical nurse specialist who they can contact between scheduled hospital visits.
People with known or suspected lung cancer know how to contact a named lung cancer specialist nurse between hospital visits.

Source clinical guideline references

NICE clinical guideline 121 recommendations 1.2.2 (key priority for implementation), 1.3.34 and 1.6.3.

Data source

Structure
Local data collection.
Process
a) Local data collection. The Department of Health National Cancer Patient Experience Survey report 2010 (data can be disaggregated for lung cancer) contained information on the proportion of patients given the name of a clinical nurse specialist and the proportion of patients reporting they found it easy to contact their clinical nurse specialist.
b) Health and Social Care Information Centre National Lung Cancer Data Audit collects data on the proportion of patients submitted to the audit who have had a lung cancer clinical nurse specialist present at diagnosis.
c) National Lung Cancer Data Audit collects data on the proportion of patients submitted to the audit who have seen a lung cancer clinical nurse specialist.
Data fields necessary for the calculation of the number of lung cancer patients who were seen by a clinical nurse specialist are available in the National Cancer Outcomes and Services dataset (in development), which is available from the National Cancer Intelligence Network.
Outcome
Local data collection. The National Cancer Patient Experience Survey report 2010 (data can be disaggregated for lung cancer) contained information on the proportion of patients reporting they found it easy to contact their clinical nurse specialist.

Definitions

The National Cancer Peer Review Programme's Manual for Cancer Services defines the clinical nurse specialist in the lung measures 11-2C-113 and 11-2C-114 as:
A core member of the multidisciplinary team who has successfully completed a programme of study in their specialist area of nursing practice, which has been accredited for at least 20 credits at first degree level or equivalent.
Responsibilities include:
  • contributing to the multidisciplinary discussion and patient assessment/care planning decision of the team at their regular meetings
  • providing expert nursing advice and support to other health professionals in the nurse's specialist area of practice
  • involvement in clinical audit
  • leading on patient and carer communication issues and coordination of the patient pathway for patients referred to the team – acting as the key worker or responsible for nominating the key worker for the patient's dealings with the team
  • ensuring that results of patients' holistic needs assessment are taken into account in the decision-making
  • contributing to the management of the service
  • utilising research in the nurse's specialist area of practice.

Holistic needs assessment

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People with lung cancer are offered a holistic needs assessment at each key stage of care that informs their care plan and the need for referral to specialist services.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with lung cancer are offered a holistic needs assessment at each key stage of care that informs their care plan and the need for referral to specialist services.
Process
a) Proportion of people with lung cancer who have a care plan based on a holistic needs assessment undertaken at diagnosis.
Numerator – the number of people in the denominator who have a care plan based on a holistic needs assessment undertaken at diagnosis.
Denominator – the number of people with lung cancer.
b) Proportion of people with lung cancer who have a care plan based on a holistic needs assessment undertaken at diagnosis and other key stages of care.
Numerator – the number of people in the denominator who have a care plan based on a holistic needs assessment undertaken at diagnosis and other key stages of care.
Denominator – the number of people with lung cancer.
c) Proportion of people with lung cancer who receive specialist services as a result of a care plan based on a holistic needs assessment.
Numerator – the number of people in the denominator who receive specialist services as a result of a care plan based on a holistic needs assessment.
Denominator – the number of people with lung cancer.
Outcome
a) Patient satisfaction with support offered.
b) Patient satisfaction with support received.

Description of what the quality statement means for each audience

Service providers ensure that services are in place for people with lung cancer to be offered a holistic needs assessment at each key stage of care that informs their care plan and the need for referral to specialist services.
Healthcare professionals offer people with lung cancer a holistic needs assessment at each key stage of care that informs their care plan and the need for referral to specialist services.
Commissioners ensure they commission services for people with lung cancer to be offered a holistic needs assessment at each key stage of care that informs their care plan and the need for referral to specialist services.
People with lung cancer are offered an assessment of all their needs at each stage of care, the results of which are used to form part of their care plan and indicate whether referral to a specialist service is necessary.

Source clinical guideline references

Improving supportive and palliative care for adults with cancer (NICE cancer service guidance SP) recommendations KR2, KR13, KR14 (key recommendations) and 8.10.

Data source

Structure
Local data collection.
Process
a), b) and c) Local data collection.
Outcome
a) Local data collection. The Department of Health National Cancer Patient Experience Survey report 2010 (data can be disaggregated for lung cancer) contained information on the proportion of patients who were given information about support and self-help groups for people with cancer, and the proportion of patients that received information from hospital staff about how to get financial help or benefits.
b) Local data collection.

Definitions

A holistic needs assessment should consider all aspects of a person's needs, including physical, social, psychological and spiritual. Assessments should encompass all aspects of supportive and palliative care, including the preferences of patients and carers with respect to:
  • written and other forms of information
  • face-to-face communication
  • involvement in decision-making
  • control of physical symptoms
  • psychological support
  • social support
  • spiritual support
  • rehabilitation
  • complementary therapies
  • self-management and peer support
  • family support
  • bereavement support
  • involvement in the design and delivery of services
  • financial support
  • smoking cessation advice and support.
Key stages of care include diagnosis, starting treatment, during treatment, at the end of treatment, at relapse and when death is approaching.
People referred for specialist services should receive them within a timeframe that does not cause avoidable physical, social, psychological or spiritual distress and should not exceed 2 weeks.
Specialist services include respiratory medicine, clinical and medical oncology, surgery, palliative care, lung cancer clinical nurse specialists, smoking cessation, psychological support services and other non-core services where there are clinical indications (for example cardiology).

Investigations

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People with lung cancer, following initial assessment and computed tomography (CT) scan, are offered investigations that give the most information about diagnosis and staging with the least risk of harm.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with lung cancer following initial assessment and CT scan are offered investigations that give the most information about diagnosis and staging with the least risk of harm.
Process
a) Proportion of people with lung cancer following initial assessment and CT scan who have pathologically confirmed mediastinal staging.
Numerator – the number of people in the denominator who have pathologically confirmed mediastinal staging.
Denominator – the number of people with lung cancer following initial assessment and CT scan.
b) Proportion of people with lung cancer following initial assessment and CT scan who receive two or more invasive tests for diagnostic and staging purposes.
Numerator – the number of people in the denominator who receive two or more invasive tests for diagnostic and staging purposes.
Denominator – the number of people with lung cancer following initial assessment and CT scan.
Outcome
a) Complications following invasive or minimally invasive tests.
b) Histological confirmation rate.
c) People with lung cancer who have stage recorded.

Description of what the quality statement means for each audience

Service providers ensure there are systems in place for people with lung cancer following initial assessment and CT scan to be offered investigations that give the most information about diagnosis and staging with the least risk of harm.
Healthcare professionals offer people with lung cancer investigations that give the most information about diagnosis and staging with the least risk of harm, following initial assessment and CT scan.
Commissioners ensure they commission services for people with lung cancer following initial assessment and CT scan to be offered investigations that give the most information about diagnosis and staging with the least risk of harm.
People with lung cancer, after their first assessment and CT scan (a type of scan that uses X-rays to obtain images of inside the body), are offered further tests that give the most information about the type and stage of their cancer with the least risk of harm.

Source clinical guideline references

NICE clinical guideline 121 recommendations 1.3.1–1.3.11, 1.3.12 (key priority for implementation), 1.3.13–1.3.17, 1.3.18 (key priority for implementation) and 1.3.19–1.3.29.

Data source

Structure
Local data collection.
Process
a) and b) Local data collection.
Outcome
a) Local data collection.
b) and c) The Health and Social Care Information Centre National Lung Cancer Data Audit collects data on the proportion of patients submitted to the audit who have a histologically confirmed diagnosis of lung cancer with stage recorded.

Definitions

Diagnostic and staging algorithms can be found in appendix C of NICE clinical guideline 121, including a clinical pathway and details for mediastinal staging.

Tissue diagnosis

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People with lung cancer have adequate tissue samples taken in a suitable form to provide a complete pathological diagnosis including tumour typing and sub-typing, and analysis of predictive markers.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with lung cancer have adequate tissue samples taken in a suitable form to provide a complete pathological diagnosis including tumour typing and sub-typing, and analysis of predictive markers.
Process
a) Proportion of people with lung cancer who have a second diagnostic test in order to obtain additional pathological information.
Numerator – the number of people in the denominator who have a second diagnostic test in order to obtain additional pathological information.
Denominator – the number of people with lung cancer.
b) Proportion of people with lung cancer who have a pathological diagnosis.
Numerator – the number of people in the denominator who have a pathological diagnosis.
Denominator – the number of people with lung cancer.
c) Proportion of people with lung cancer who have a tumour type identified.
Numerator – the number of people in the denominator who have a tumour type identified.
Denominator – the number of people with lung cancer.
d) Proportion of people with non-small-cell lung cancer who have a tumour sub-type identified.
Numerator – the number of people in the denominator who have a tumour sub-type identified.
Denominator – the number of people with non-small-cell lung cancer.
e) Proportion of people with non-small-cell lung cancer where reported tumour sub-type is 'not otherwise specified'.
Numerator – the number of people in the denominator where reported tumour sub-type is 'not otherwise specified'.
Denominator – the number of people with non-small-cell lung cancer.
f) Proportion of people with lung cancer who have an analysis of predictive markers.
Numerator – the number of people in the denominator who have an analysis of predictive markers.
Denominator – the number of people with lung cancer.

Description of what the quality statement means for each audience

Service providers ensure there are systems in place for people with lung cancer to have adequate tissue samples taken in a suitable form to provide a complete pathological diagnosis including tumour typing and sub-typing, and analysis of predictive markers.
Healthcare professionals take adequate tissue samples in a suitable form to provide a complete pathological diagnosis including tumour typing and sub-typing, and analysis of predictive markers, for people with lung cancer.
Commissioners ensure they commission services for people with lung cancer to have adequate tissue samples taken in a suitable form to provide a complete pathological diagnosis including tumour typing and sub-typing, and analysis of predictive markers.
People with lung cancer have a sample of tumour tissue removed for laboratory analysis, which will give enough information about the type and sub-type of the tumour to give a complete diagnosis.

Source clinical guideline references

NICE clinical guideline 121 recommendation 1.3.11.

Data source

Structure
Local data collection.
Process
a) Local data collection.
b) The Health and Social Care Information Centre National Lung Cancer Data Audit collects data on the proportion of patients submitted to the audit who have a histologically or cytologically confirmed diagnosis of lung cancer.
c) and f) Local data collection.
d) and e) National Lung Cancer Data Audit collects data on the proportion of patients submitted to the audit with non-small-cell lung cancer where the sub-type is limited to 'not otherwise specified'.

Definitions

Tumour sub-typing is the pathological classification of tumours into sub-types according to the differentiation of the cell type.
Predictive markers are molecular characteristics of the tumour that may predict response to systemic therapy.
A complete pathological diagnosis is set out in The Royal College of Pathologists Dataset for lung cancer histopathology reports.

Curative treatment in people of borderline fitness

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People with resectable lung cancer who are of borderline fitness and not initially accepted for surgery are offered the choice of a second surgical opinion, and a multidisciplinary team opinion on non-surgical treatment with curative intent.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with resectable lung cancer who are of borderline fitness and not initially accepted for surgery are offered the choice of a second surgical opinion, and a multidisciplinary team opinion on non-surgical treatment with curative intent.
Process
a) Proportion of people with resectable lung cancer who are of borderline fitness and not initially accepted for surgery who are offered the choice of a second surgical opinion, and a multidisciplinary team opinion on non-surgical treatment with curative intent.
Numerator – the number of people in the denominator who are offered the choice of a second surgical opinion, and a multidisciplinary team opinion on non-surgical treatment with curative intent.
Denominator – the number of people with resectable lung cancer who are of borderline fitness and not initially accepted for surgery.
b) Proportion of people with resectable lung cancer who are of borderline fitness and not initially accepted for surgery who receive non-surgical treatment with curative intent.
Numerator – the number of people in the denominator who receive non-surgical treatment with curative intent.
Denominator – the number of people with resectable lung cancer who are of borderline fitness and not initially accepted for surgery.
Outcome
a) 30-day mortality rates following surgical resection.
b) 60-day mortality rates following surgical resection.
c) Resection rates.

Description of what the quality statement means for each audience

Service providers ensure that systems are in place for people with resectable lung cancer who are of borderline fitness and not initially accepted for surgery to be offered the choice of a second surgical opinion, and a multidisciplinary team opinion on non-surgical treatment with curative intent.
Healthcare professionals offer people with resectable lung cancer who are of borderline fitness and not initially accepted for surgery the choice of a second surgical opinion, and a multidisciplinary team opinion on non-surgical treatment with curative intent.
Commissioners ensure they commission services for people with resectable lung cancer who are of borderline fitness and not initially accepted for surgery to be offered the choice of a second surgical opinion, and a multidisciplinary team opinion on non-surgical treatment with curative intent.
People with lung cancer that can be removed by surgery who are not initially accepted for surgery because their level of fitness is considered to be 'borderline', which means that surgery might be too risky for them, are offered a second opinion on whether surgery is suitable for them and the opinion of their multidisciplinary team on suitable treatments other than surgery to try and cure their cancer.

Source clinical guideline references

NICE clinical guideline 121 recommendation 1.4.20 (key priority for implementation), 1.4.31 and 1.4.32.

Data source

Structure
Local data collection.
Process
a) and b) Local data collection.
Outcome
a) and b) Linked Office for National Statistics and Hospital episodes and statistics mortality data contain the data necessary for the calculation of 30- and 60-day mortality rates following surgical resection.
c) The Health and Social Care Information Centre National Lung Cancer Data Audit collects data on the proportion of patients receiving surgery.

Definitions

Borderline fitness is defined as a level of fitness that could lead to a greater than average morbidity or mortality from surgery. This includes those patients with poor lung function who are at risk of increased postoperative dyspnoea that would be sufficient to be unacceptable to them (this is subjective and will vary from patient to patient). Patients may have an increased risk of cardiovascular morbidity that might lead to a perioperative complication or death. Borderline fitness also includes patients who have a higher than average risk of perioperative mortality.

Access to specialist assessment

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People with lung cancer are offered assessment for multimodality treatment by a multidisciplinary team comprising all specialist core members.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with lung cancer are offered assessment for multimodality treatment by a multidisciplinary team comprising all specialist core members.
Process
Proportion of people with lung cancer who receive assessment for multimodality treatment by a multidisciplinary team comprising all specialist core members.
Numerator – the number of people in the denominator who receive assessment for multimodality treatment by a multidisciplinary team comprising all specialist core members.
Denominator – the number of people with lung cancer.
Outcome
a) Surgery rates.
b) Multimodality rates.
c) Radiotherapy rates.
d) Overall active treatment rates.
e) Chemotherapy rate for small-cell lung cancer.
f) Chemotherapy rate for stage IIIB and IV (performance status 0 and 1) non-small-cell lung cancer.

Description of what the quality statement means for each audience

Service providers ensure that services are in place for people with lung cancer to be offered assessment for multimodality treatment by a multidisciplinary team comprising all specialist core members.
Healthcare professionals offer people with lung cancer assessment for multimodality treatment by a multidisciplinary team comprising all specialist core members.
Commissioners ensure they commission services for people with lung cancer to be offered assessment for multimodality treatment by a multidisciplinary team comprising all specialist core members.
People with lung cancer are offered an assessment by their multidisciplinary team involving all of the key specialists to see if a combination of more than one treatment is suitable for them.

Source clinical guideline references

NICE clinical guideline 121 recommendations 1.4.19, 1.4.31 and 1.4.33 (key priority for implementation).

Data source

Structure
Local data collection. The National Cancer Peer Review measure 08-2C-102 will collect data on the multidisciplinary team structure and named core members.
Process
Local data collection.
Outcome
a), b), c), d), e) and f) The Health and Social Care Information Centre National Lung Cancer Data Audit collects data on the proportion of patients submitted to the audit receiving treatment, broken down by treatment type.

Definitions

Specialist core members of a multidisciplinary team, as detailed in the National Cancer Peer Review Programme's Manual for Cancer Services in lung measure 11-2C-101, are:
  • designated respiratory physician(s)
  • designated thoracic surgeon(s)
  • a clinical oncologist
  • a medical oncologist (where the responsibility of chemotherapy is not undertaken by the clinical oncologist core member)
  • an imaging specialist
  • a histopathologist
  • a designated cytologist
  • a lung nurse specialist
  • a core member of the specialist palliative care team.

Access to radiotherapy

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People with lung cancer stage I–III and good performance status who are unable to undergo surgery are assessed for radiotherapy with curative intent by a clinical oncologist specialising in thoracic oncology.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with lung cancer stage I–III and good performance status who are unable to undergo surgery are assessed for radiotherapy with curative intent by a clinical oncologist specialising in thoracic oncology.
Process
Proportion of people with lung cancer stage I–III and good performance status who are assessed for radiotherapy with curative intent by a clinical oncologist specialising in thoracic oncology.
Numerator – the number of people in the denominator who are assessed for radiotherapy with curative intent by a clinical oncologist specialising in thoracic oncology.
Denominator – the number of people with lung cancer stage I–III and good performance status.

Description of what the quality statement means for each audience

Service providers ensure there are systems in place for people with lung cancer stage I–III and good performance status who are unable to undergo surgery to be assessed for radiotherapy with curative intent by a clinical oncologist specialising in thoracic oncology.
Clinical oncologists specialising in thoracic oncology assess people with lung cancer stage I–III and good performance status who are unable to undergo surgery for radiotherapy with curative intent.
Commissioners ensure they commission services for people with lung cancer stage I–III and good performance status who are unable to undergo surgery to be assessed for radiotherapy with curative intent by a clinical oncologist specialising in thoracic oncology.
People with early or locally spread (stage I–III) lung cancer and general good health who are unable to have surgery are assessed by a specialist in cancers of the chest (a clinical oncologist specialising in thoracic oncology) to see if radiotherapy to try and cure the cancer would be suitable for them.

Source clinical guideline references

NICE clinical guideline 121 recommendations 1.4.19 and 1.4.31.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

A good performance status is defined as categories 0–2 on the World Health Organisation WHO performance scale.
People with lung cancer stage I–III with good performance status may be unable to undergo surgery because the tumour is not resectable, the perioperative risk is high because of comorbidities, or the person declines surgery.

Optimal radiotherapy

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People with lung cancer stage I–III and good performance status who are offered radiotherapy with curative intent receive planned treatment techniques that optimise the dose to the tumour while minimising the risks of normal tissue damage.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with lung cancer stage I–III and good performance status who are offered radiotherapy with curative intent receive planned treatment techniques that optimise the dose to the tumour while minimising the risks of normal tissue damage.
Process
a) Proportion of people with lung cancer stage I–III and good performance status who receive radiotherapy with curative intent.
Numerator – the number of people in the denominator who receive radiotherapy with curative intent.
Denominator – the number of people with lung cancer stage I–III and good performance status.
b) Proportion of people with lung cancer receiving radiotherapy with curative intent who receive planned treatment techniques that optimise the dose to the tumour while minimising the risks of normal tissue damage.
Numerator – the number of people in the denominator who receive planned treatment techniques that optimise the dose to the tumour while minimising the risks of normal tissue damage.
Denominator – the number of people with lung cancer receiving radiotherapy with curative intent.

Description of what the quality statement means for each audience

Service providers ensure there are systems in place for people with lung cancer stage I–III and good performance status who are offered radiotherapy with curative intent to receive planned treatment techniques that optimise the dose to the tumour while minimising the risks of normal tissue damage.
Healthcare professionals ensure people with lung cancer stage I–III and good performance status who are offered radiotherapy with curative intent receive planned treatment techniques that optimise the dose to the tumour while minimising the risks of normal tissue damage.
Commissioners ensure they commission services for people with lung cancer I–III and good performance status who are offered radiotherapy with curative intent to receive planned treatment techniques that optimise the dose to the tumour while minimising the risks of normal tissue damage.
People with early or locally spread (stage I–III) lung cancer and general good health who are offered radiotherapy to try and cure the cancer receive treatment techniques that focus the radiation on the tumour while keeping damage to the healthy tissue to a minimum.

Source clinical guideline references

NICE clinical guideline 121 recommendation 1.4.24 (key priority for implementation), 1.4.25–1.4.30.

Data source

Structure
Local data collection.
Process
a) The Health and Social Care Information Centre National Lung Cancer Data Audit collects data on the proportion of patients submitted to the audit receiving radiotherapy.
b) Data fields necessary for the extraction of data on radiotherapy dose, fractionation and scheduling are available in the National Cancer Intelligence Network National Radiotherapy Dataset.

Definitions

A good performance status is defined as categories 0–2 on the World Health Organisation performance scale.
Examples of optimising radiotherapy techniques include 4-D radiotherapy planning and treatment, image-guided radiotherapy, intensity-modulated radiotherapy and stereotactic body radiotherapy.

Systemic therapy for advanced non-small-cell lung cancer

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People with stage IIIB or IV non-small-cell lung cancer and eligible performance status are offered systemic therapy (first- and second-line) in accordance with NICE guidance, that is tailored to the pathological sub-type of the tumour and individual predictive factors.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with stage IIIB or IV non-small-cell lung cancer and eligible performance status are offered systemic therapy (first- and second-line) in accordance with NICE guidance, that is tailored to the pathological sub-type of the tumour and individual predictive factors.
Process
a) Proportion of people with stage IIIB or IV non-small-cell lung cancer and eligible performance status who receive first-line systemic therapy in accordance with NICE guidance, that is tailored to the pathological sub-type of the tumour and individual predictive factors.
Numerator – the number of people in the denominator who receive first-line systemic therapy in accordance with NICE guidance, that is tailored to the pathological sub-type of the tumour and individual predictive factors.
Denominator – the number of people with stage IIIB or IV non-small-cell lung cancer and eligible performance status.
b) Proportion of people with advanced stage IIIB or IV non-small-cell lung cancer and eligible performance status who receive second-line systemic therapy in accordance with NICE guidance, that is tailored to the pathological sub-type of the tumour and individual predictive factors.
Numerator – the number of people in the denominator who receive second-line systemic therapy in accordance with NICE guidance, that is tailored to the pathological sub-type of the tumour and individual predictive factors.
Denominator – the number of people with advanced stage IIIB or IV non-small-cell lung cancer and eligible performance status.

Description of what the quality statement means for each audience

Service providers ensure there are systems in place for people with stage IIIB or IV non-small-cell lung cancer and eligible performance status to be offered systemic therapy (first- and second-line) in accordance with NICE guidance, that is tailored to the pathological sub-type of the tumour and individual predictive factors.
Healthcare professionals offer systemic therapy (first- and second-line) to people with stage IIIB or IV non-small-cell lung cancer and eligible performance status in accordance with NICE guidance, that is tailored to the pathological sub-type of the tumour and individual predictive factors.
Commissioners ensure they commission services for people with stage IIIB or IV non-small-cell lung cancer and eligible performance status to be offered systemic therapy (first- and second-line) in accordance with NICE guidance, that is tailored to the pathological sub-type of the tumour and individual predictive factors.
People with advanced (stage IIIB or IV) non-small-cell lung cancer and good general health are offered chemotherapy in accordance with NICE guidance, and tailored to the type of the tumour and individual factors.

Source clinical guideline references

NICE clinical guideline 121 recommendations 1.4.40–1.4.43.
NICE technology appraisal guidance 181 recommendations 1.1–1.2.

Data source

Structure
Local data collection.
Process
a) The Health and Social Care Information Centre National Lung Cancer Data Audit collects data on the proportion of patients submitted to the audit receiving chemotherapy for stage IIIB and IV (performance status 0 and 1) non-small-cell lung cancer.
b) Local data collection. Contained in the NICE audit support for lung cancer (NICE clinical guideline 121): treatment for patients with non-small-cell lung cancer, criteria 21–30.
Data fields necessary for the extraction of data on patients receiving cancer chemotherapy are available in the National Cancer Intelligence Network Systemic Anti-Cancer Therapy dataset.

Definitions

Eligible performance status is defined as categories 0-2 on the World Health Organisation performance scale.
Systemic therapy includes conventional cytotoxic chemotherapy and biological agents that target specific molecular pathways on the tumour to inhibit cellular function.
People with stage IIIB or IV non-small-cell lung cancer and eligible performance status are offered systemic therapy in accordance with NICE clinical guideline 121 recommendations 1.4.40–1.4.43.

Small-cell lung cancer

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People with small-cell lung cancer have treatment initiated within 2 weeks of the pathological diagnosis.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with small-cell lung cancer have treatment initiated within 2 weeks of the pathological diagnosis.
Process
Proportion of people with small-cell lung cancer who have treatment initiated within 2 weeks of the pathological diagnosis.
Numerator – the number of people in the denominator who have treatment initiated within 2 weeks of the pathological diagnosis.
Denominator – the number of people with small-cell lung cancer.

Description of what the quality statement means for each audience

Service providers ensure that systems are in place for people with small-cell lung cancer to have treatment initiated within 2 weeks of the pathological diagnosis.
Healthcare professionals initiate treatment for people with small-cell lung cancer within 2 weeks of the pathological diagnosis.
Commissioners ensure they commission services for people with small-cell lung cancer to have treatment initiated within 2 weeks of the pathological diagnosis.
People with small-cell lung cancer have treatment started within 2 weeks of their diagnosis.

Source clinical guideline references

NICE clinical guideline 121 recommendation 1.4.44 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Data fields necessary for the calculation of the interval between the date of tissue diagnosis and date of first chemotherapy treatment are available in the National Cancer Outcomes and Services dataset (in development), which is available from the National Cancer Intelligence Network.
The Health and Social Care Information Centre National Lung Cancer Data Audit collects data on the proportion of small-cell lung cancer patients submitted to the audit receiving treatment within a given timeframe.

Definitions

Treatment for small-cell lung cancer is in accordance with NICE clinical guideline 121 recommendations 1.4.45–1.4.47 and 1.4.49–1.4.58, and NICE technology appraisal guidance 184.

Optimal follow-up regime

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People with lung cancer are offered a specialist follow-up appointment within 6 weeks of completing initial treatment and regular specialist follow-up thereafter, which can include protocol-led clinical nurse specialist follow-up.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with lung cancer are offered a specialist follow-up appointment within 6 weeks of completing initial treatment and regular specialist follow-up thereafter, which can include protocol-led clinical nurse specialist follow-up.
Process
a) Proportion of people with lung cancer who receive a specialist follow-up appointment within 6 weeks of completing initial treatment.
Numerator – the number of people who receive a specialist follow-up appointment within 6 weeks of completing initial treatment.
Denominator – the number of people with lung cancer who complete initial treatment.
b) Proportion of people with lung cancer who receive regular specialist or protocol-led clinical nurse specialist follow-up after completing initial treatment.
Numerator – the number of people in the denominator who receive regular specialist or protocol-led clinical nurse specialist follow-up after completing initial treatment
Denominator – the number of people with lung cancer who complete initial treatment.
Outcome
Patient satisfaction with follow-up care.

Description of what the quality statement means for each audience

Service providers ensure that systems are in place for people with lung cancer to be offered a specialist follow-up appointment within 6 weeks of completing initial treatment and regular specialist follow-up thereafter, which can include protocol-led clinical nurse specialist follow-up.
Healthcare professionals offer people with lung cancer a specialist follow-up appointment within 6 weeks of completing initial treatment and regular specialist follow-up thereafter, which can include protocol-led clinical nurse specialist follow-up.
Commissioners ensure they commission services for people with lung cancer to be offered a specialist follow-up appointment within 6 weeks of completing initial treatment and regular specialist follow-up thereafter, which can include protocol-led clinical nurse specialist follow-up.
People with lung cancer are offered a specialist follow-up appointment within 6 weeks of completing initial treatment, and regular follow-up appointments with a specialist or the lung cancer specialist nurse.

Source clinical guideline references

NICE clinical guideline 121 recommendation 1.6.1 (key priority for implementation) and 1.6.2.

Data source

Structure
Local data collection.
Process
a) and b) Local data collection. Contained in the NICE audit support for lung cancer (NICE clinical guideline 121): palliative interventions and supportive and palliative care, criterion 9.
Outcome
Local data collection.

Definitions

Regularity of further follow-up will be determined by patient preference.
Protocol-led follow-up means that the indications for follow-up by a clinical nurse specialist, the content of that follow-up and the actions to be taken in response to findings, are agreed in writing in a structured format.

Palliative interventions

This quality statement is taken from the Lung cancer quality standard. The quality standard defines clinical best practice in lung cancer care and should be read in full.

Quality statement

People with lung cancer have access to all appropriate palliative interventions delivered by expert clinicians and teams.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with lung cancer have access to all appropriate palliative interventions delivered by expert clinicians and teams.
Process
a) Proportion of people with lung cancer and bronchial obstruction who receive endobronchial treatments.
Numerator – the number of people in the denominator who receive endobronchial treatments.
Denominator – the number of people with lung cancer and bronchial obstruction.
b) Proportion of people with lung cancer and pleural effusion who receive pleural aspiration or drainage.
Numerator – the number of people in the denominator who receive pleural aspiration or drainage.
Denominator – the number of people with lung cancer and pleural effusion.

Description of what the quality statement means for each audience

Service providers ensure that systems are in place for people with lung cancer to have access to all appropriate palliative interventions delivered by expert clinicians and teams.
Healthcare professionals provide access to all appropriate palliative interventions delivered by expert clinicians and teams, for people with lung cancer.
Commissioners ensure they commission services for people with lung cancer to have access to all appropriate palliative interventions delivered by expert clinicians and teams.
People with lung cancer can access appropriate palliative treatments and care (palliative treatment and care helps with pain, discomfort and other symptoms and improves quality of life), from expert clinicians and healthcare teams.

Source clinical guideline references

NICE clinical guideline 121 recommendation 1.5.3-1.5.5, 1.5.6 (key priority for implementation) 1.5.7-1.5.18.

Data source

Structure
Local data collection.
Process
a) and b) Local data collection.
Contained in (NICE audit support for lung cancer 3) (NICE clinical guideline 121): palliative interventions and supportive and palliative care, criteria 3–4.

Definitions

Appropriate palliative interventions include:
  • palliative chemotherapy
  • palliative radiotherapy
  • endobronchial treatments (including radiotherapy, brachytherapy, photodynamic therapy, electrocautery, cryotherapy, laser, stenting and debulking)
  • pleural aspiration or drainage
  • non-drug interventions (psychosocial support, breathing control and coping strategies).
Expert clinicians and teams refer to specialist palliative care teams that should include palliative medicine consultants and palliative care nurse specialists together with a range of expertise provided by physiotherapists, occupational therapists, pharmacists, social workers and those able to give spiritual and psychological support.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Confirm negative results obtained by non-ultrasound-guided TBNA using EBUS-guided TBNA, EUS-guided FNA or surgical staging.
Confirm negative results obtained by EBUS-guided TBNA and/or EUS-guided FNA using surgical staging if clinical suspicion of mediastinal malignancy is high.
Consider combined EBUS and EUS for initial staging of the mediastinum as an alternative to surgical staging.
NICE has produced guidance on EBUS-TBNA for mediastinal masses (NICE interventional procedure guidance 254).
The patient access scheme for erlotinib has changed. The Department of Health and the manufacturer have agreed that erlotinib will be offered to the NHS under a patient access scheme (as revised in 2012), which makes erlotinib available with a discount on the list price applied to original invoices. The discount applies for all indications of erlotinib.
The size of the discount is commercial in confidence. It is the responsibility of the manufacturer to communicate details of the discount to relevant NHS organisations. Any enquiries from NHS organisations about the patient access scheme should be directed to Roche Customer Care (0800 731 5711).
NICE technology appraisal guidance 162 is under review. Publication of the reviewed guidance is expected in 2014.

Glossary

Endobronchial ultrasound.
Endoscopic ultrasound.
Fine needle aspiration.
Multidisciplinary team.
Non-small-cell lung cancer.
Small-cell lung cancer.
Transbronchial needle aspiration.

Paths in this pathway

Pathway created: March 2012 Last updated: October 2014

© NICE 2014

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