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Lung cancer

About

What is covered

This NICE Pathway covers diagnosing and managing non-small-cell and small-cell lung cancer. It aims to improve outcomes for patients by ensuring that the most effective tests and treatments are used, and that people have access to suitable palliative care and follow-up.

Updates

Updates to this NICE Pathway

1 July 2020 added:
12 May 2020 Lorlatinib for previously treated ALK-positive advanced non-small-cell lung cancer (NICE technology appraisal guidance 628) added to second- or third-line treatment for ALK-positive mutation.
21 January 2020 Osimertinib for untreated EGFR mutation-positive non-small-cell lung cancer (NICE technology appraisal guidance 621) added to first-line treatment for EGFR-TK mutation.
14 January 2020 Atezolizumab with carboplatin and nab-paclitaxel for untreated advanced non-squamous non-small-cell lung cancer (terminated appraisal) (NICE technology appraisal 618) added to drugs not recommended for non-squamous non-small-cell lung cancer.
12 December 2019 Lung cancer in adults (NICE quality standard 17) updated.
10 September 2019 Pembrolizumab with carboplatin and paclitaxel for untreated metastatic squamous non-small-cell lung cancer (NICE technology appraisal guidance 600) added to first-line treatment for squamous non-small-cell lung cancer PD-L1 under 50% and PD-L1 50% and over.
13 August 2019 Dacomitinib for untreated EGFR mutation-positive non-small-cell lung cancer (NICE technology appraisal guidance 595) added to first-line treatment for EGFR-TK mutation.
4 June 2019 Atezolizumab in combination for treating metastatic non-squamous non-small-cell lung cancer (NICE technology appraisal guidance 584) added to EGFR-TK mutation, ALK-positive and PD-L1 under 50% treatments.
30 April 2019 Durvalumab for treating locally advanced unresectable non-small-cell lung cancer after platinum-based chemoradiation (NICE technology appraisal guidance 578) added to durvalumab after platinum-based chemoradiation.
27 March 2019 Updated and restructured on publication of the update of lung cancer: diagnosis and management (NICE guideline NG122).
19 March 2019 Brigatinib for treating ALK-positive advanced non-small-cell lung cancer after crizotinib (NICE technology appraisal guidance 571) added.
26 February 2019 Dabrafenib with trametinib for treating advanced metastatic BRAF V600E mutation-positive non-small-cell lung cancer (terminated appraisal) (NICE technology appraisal 564) added.
7 August 2018 Alectinib for untreated ALK-positive advanced non-small-cell lung cancer (NICE technology appraisal guidance 536) added.
17 July 2018 Pembrolizumab for untreated PD-L1-positive metastatic non-small-cell lung cancer (NICE technology appraisal guidance 531) updated.
3 July 2018 Crizotinib for treating ROS1-positive advanced non-small-cell lung cancer (NICE technology appraisal guidance 529) added.
15 May 2018 Atezolizumab for treating locally advanced or metastatic non-small-cell lung cancer after chemotherapy (NICE technology appraisal guidance 520) added.
20 March 2018 Thopaz+ portable digital system for managing chest drains (NICE medical technologies guidance 37) added.
19 February 2018 Recommendations updated in treatment-resistant recurrent ascites related to the cost savings of NICE medical technologies guidance on PleurX peritoneal catheter drainage system for vacuum-assisted drainage of treatment-resistant, recurrent malignant ascites.
30 November 2016 Structure revised, and summarised recommendations replaced with full recommendations.
31 March 2016 Depth of anaesthesia monitors – Bispectral Index (BIS), E-Entropy and Narcotrend-Compact M (NICE diagnostics guidance 6) added.
22 June 2015 Recommendations in symptoms and signs indicating urgent chest X-ray and urgent and immediate referral updated on publication of suspected cancer: recognition and referral (NICE guideline NG12).
26 November 2013 Microwave ablation for treating primary lung cancer and metastases in the lung (NICE interventional procedures guidance 469) added to ablation procedures for treating small-cell lung cancer and ablation procedures for primary and secondary non-small-cell lung cancers.
13 August 2013 EGFR-TK mutation testing in adults with locally advanced or metastatic non-small-cell lung cancer (NICE diagnostics guidance 9) 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 supportive and palliative care for lung cancer.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and treating lung cancer in an interactive flowchart

What is covered

This NICE Pathway covers diagnosing and managing non-small-cell and small-cell lung cancer. It aims to improve outcomes for patients by ensuring that the most effective tests and treatments are used, and that people have access to suitable palliative care and follow-up.

Updates

Updates to this NICE Pathway

1 July 2020 added:
12 May 2020 Lorlatinib for previously treated ALK-positive advanced non-small-cell lung cancer (NICE technology appraisal guidance 628) added to second- or third-line treatment for ALK-positive mutation.
21 January 2020 Osimertinib for untreated EGFR mutation-positive non-small-cell lung cancer (NICE technology appraisal guidance 621) added to first-line treatment for EGFR-TK mutation.
14 January 2020 Atezolizumab with carboplatin and nab-paclitaxel for untreated advanced non-squamous non-small-cell lung cancer (terminated appraisal) (NICE technology appraisal 618) added to drugs not recommended for non-squamous non-small-cell lung cancer.
12 December 2019 Lung cancer in adults (NICE quality standard 17) updated.
10 September 2019 Pembrolizumab with carboplatin and paclitaxel for untreated metastatic squamous non-small-cell lung cancer (NICE technology appraisal guidance 600) added to first-line treatment for squamous non-small-cell lung cancer PD-L1 under 50% and PD-L1 50% and over.
13 August 2019 Dacomitinib for untreated EGFR mutation-positive non-small-cell lung cancer (NICE technology appraisal guidance 595) added to first-line treatment for EGFR-TK mutation.
4 June 2019 Atezolizumab in combination for treating metastatic non-squamous non-small-cell lung cancer (NICE technology appraisal guidance 584) added to EGFR-TK mutation, ALK-positive and PD-L1 under 50% treatments.
30 April 2019 Durvalumab for treating locally advanced unresectable non-small-cell lung cancer after platinum-based chemoradiation (NICE technology appraisal guidance 578) added to durvalumab after platinum-based chemoradiation.
27 March 2019 Updated and restructured on publication of the update of lung cancer: diagnosis and management (NICE guideline NG122).
19 March 2019 Brigatinib for treating ALK-positive advanced non-small-cell lung cancer after crizotinib (NICE technology appraisal guidance 571) added.
26 February 2019 Dabrafenib with trametinib for treating advanced metastatic BRAF V600E mutation-positive non-small-cell lung cancer (terminated appraisal) (NICE technology appraisal 564) added.
7 August 2018 Alectinib for untreated ALK-positive advanced non-small-cell lung cancer (NICE technology appraisal guidance 536) added.
17 July 2018 Pembrolizumab for untreated PD-L1-positive metastatic non-small-cell lung cancer (NICE technology appraisal guidance 531) updated.
3 July 2018 Crizotinib for treating ROS1-positive advanced non-small-cell lung cancer (NICE technology appraisal guidance 529) added.
15 May 2018 Atezolizumab for treating locally advanced or metastatic non-small-cell lung cancer after chemotherapy (NICE technology appraisal guidance 520) added.
20 March 2018 Thopaz+ portable digital system for managing chest drains (NICE medical technologies guidance 37) added.
19 February 2018 Recommendations updated in treatment-resistant recurrent ascites related to the cost savings of NICE medical technologies guidance on PleurX peritoneal catheter drainage system for vacuum-assisted drainage of treatment-resistant, recurrent malignant ascites.
30 November 2016 Structure revised, and summarised recommendations replaced with full recommendations.
31 March 2016 Depth of anaesthesia monitors – Bispectral Index (BIS), E-Entropy and Narcotrend-Compact M (NICE diagnostics guidance 6) added.
22 June 2015 Recommendations in symptoms and signs indicating urgent chest X-ray and urgent and immediate referral updated on publication of suspected cancer: recognition and referral (NICE guideline NG12).
26 November 2013 Microwave ablation for treating primary lung cancer and metastases in the lung (NICE interventional procedures guidance 469) added to ablation procedures for treating small-cell lung cancer and ablation procedures for primary and secondary non-small-cell lung cancers.
13 August 2013 EGFR-TK mutation testing in adults with locally advanced or metastatic non-small-cell lung cancer (NICE diagnostics guidance 9) 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 supportive and palliative care for lung cancer.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Lung cancer: diagnosis and management (2019) NICE guideline NG122
Ceritinib for untreated ALK-positive non-small-cell lung cancer (2018) NICE technology appraisal guidance 500
Nivolumab for previously treated squamous non-small-cell lung cancer (2017) NICE technology appraisal guidance 483
Pemetrexed for the maintenance treatment of non-small-cell lung cancer (2010 updated 2017) NICE technology appraisal guidance 190
Topotecan for the treatment of relapsed small-cell lung cancer (2009) NICE technology appraisal guidance 184
Pemetrexed for the first-line treatment of non-small-cell lung cancer (2009) NICE technology appraisal guidance 181
Pemetrexed for the treatment of non-small-cell lung cancer (2007) NICE technology appraisal guidance 124
Microwave ablation for treating primary lung cancer and metastases in the lung (2013) NICE interventional procedures guidance 469
Percutaneous radiofrequency ablation for primary and secondary lung cancers (2010) NICE interventional procedures guidance 372
Cryotherapy for malignant endobronchial obstruction (2005) NICE interventional procedures guidance 142
Photodynamic therapy for localised inoperable endobronchial cancer (2005) NICE interventional procedures guidance 137
Photodynamic therapy for advanced bronchial carcinoma (2004) NICE interventional procedures guidance 87
Stent placement for vena caval obstruction (2004) NICE interventional procedures guidance 79
Thopaz+ portable digital system for managing chest drains (2018) NICE medical technologies guidance 37
Lung cancer in adults (2012 updated 2019) NICE quality standard 17

Quality standards

Lung cancer in adults

These quality statements are taken from the lung cancer in adults quality standard. The quality standard defines clinical best practice for lung cancer in adults and should be read in full.

Quality statements

Public awareness

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

Quality statement

Local authorities and healthcare commissioning groups use coordinated campaigns to raise awareness of the symptoms and signs of lung cancer and encourage people to seek medical advice if they need to.

Rationale

Diagnosing lung cancer at a late stage is associated with poor health outcomes, including shorter survival. Raising awareness of the symptoms and signs of lung cancer can encourage earlier presentation and diagnosis, including among people who have never smoked. Locally coordinated awareness campaigns can engage groups at risk in the local population. Earlier diagnosis will increase the number of adults with lung cancer able to have treatment with curative intent.

Quality measures

Structure
a) Evidence of local needs assessment to identify population groups for campaigns to raise awareness of the symptoms and signs of lung cancer and encourage people to seek medical advice if they need to.
Data source: Local data collection, for example, joint strategic needs assessment.
b) Evidence of locally coordinated campaigns to raise awareness of the symptoms and signs of lung cancer and encourage people to seek medical advice if they need to.
Data source: Local data collection, for example, campaign plans or materials such as posters, leaflets and social media messaging.
c) Evidence of evaluation of locally coordinated campaigns to raise awareness of the symptoms and signs of lung cancer and encourage people to seek medical advice if they need to.
Data source: Local data collection, for example, evaluation reports.
Outcome
a) Proportion of adults in the population who can recognise and recall the symptoms and signs of lung cancer.
Numerator – the number in the denominator who can recognise and recall the symptoms and signs of lung cancer.
Denominator – the number of adults in the population.
Data source: Local data collection, for example, a sample survey based on Cancer Research UK’s Cancer Awareness Measure.
b) Proportion of adults with a new diagnosis of lung cancer who were diagnosed via an emergency route.
Numerator – the number in the denominator who were diagnosed via an emergency route.
Denominator – the number of adults with a new diagnosis of lung cancer.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset collects data on the source of referral.
c) Proportion of adults with a new diagnosis of lung cancer diagnosed at stage I or II.
Numerator – the number in the denominator diagnosed at stage I or II.
Denominator – the number of adults with a new diagnosis of lung cancer.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.

What the quality statement means for different audiences

Local authorities and healthcare commissioning groups work together to develop and implement campaigns, tailored to the needs of the local population, to raise awareness of the symptoms and signs of lung cancer and encourage people to seek medical advice if they need to. They may also promote national lung cancer awareness campaigns locally. Local authorities and healthcare commissioning groups evaluate the impact of local campaigns, including the level of engagement with high-risk groups.
Health and social care practitioners (such as GPs, practice nurses, district nurses, community pharmacists and social care practitioners) get involved in local campaigns to raise awareness of the symptoms and signs of lung cancer and encourage people to seek medical advice if they need to.
People know about the symptoms and signs of lung cancer and are encouraged to get medical advice if they are worried about any symptoms. People know that getting advice quickly means that any cancer is more likely to be treated successfully.

Source guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendation 1.1.1

Definitions of terms used in this quality statement

Symptoms and signs of lung cancer
Symptoms and signs of lung cancer that should be investigated include:
  • 2 or more of the following unexplained symptoms in people aged 40 years and over, or 1 or more in people aged 40 years or over who have ever smoked:
    • cough
    • fatigue
    • shortness of breath
    • chest pain
    • weight loss
    • appetite loss
  • any of the following in people aged 40 years and over:
    • unexplained haemoptysis
    • persistent or recurrent chest infection
    • finger clubbing
    • supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
    • chest signs consistent with lung cancer
    • thrombocytosis.
[NICE’s guideline on suspected cancer: recognition and referral, recommendations 1.1.1, 1.1.2 and 1.1.3]

Equality and diversity considerations

Local authorities and healthcare commissioning groups should ensure that awareness campaigns include approaches that engage people living in socioeconomically deprived areas. Awareness campaigns should also be accessible to people who do not speak or read English.

Stopping smoking

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

Quality statement

Adults with suspected or confirmed lung cancer who smoke receive evidence-based stop smoking support.

Rationale

People with suspected or confirmed lung cancer who smoke should be encouraged to stop smoking to reduce the risk of treatment-related complications and other smoking-related conditions and increase their life expectancy. They should be provided with evidence-based support to help them to stop smoking.

Quality measures

Structure
a) Evidence of local arrangements to ensure that adults with suspected or confirmed lung cancer who smoke are given advice about why it is important to stop smoking.
Data source: Local data collection, for example, service protocols.
b) Evidence of local arrangements to provide evidence-based support for adults with suspected or confirmed lung cancer to help them to stop smoking.
Data source: Local data collection, for example, service specification and protocols.
Process
Proportion of adults with suspected or confirmed lung cancer who smoke who receive evidence-based support to stop smoking.
Numerator – the number in the denominator who receive evidence-based support to stop smoking.
Denominator – the number of adults with suspected or confirmed lung cancer who smoke.
Data source: Royal College of Physicians National Lung Cancer Audit (measure in development). Data on smoking status and whether treatment for tobacco addiction was given from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.
Outcome
a) Smoking rates in adults with lung cancer having treatment with curative intent.
Data source: Local data collection, for example, audit of patient records.
b) 1-year survival rate for adults with lung cancer treated with curative intent.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.

What the quality statement means for different audiences

Service providers (such as primary care, community services, secondary and tertiary care) ensure that processes are in place to provide advice to adults with suspected or confirmed lung cancer who smoke about why it is important to stop smoking. Providers ensure that they can provide evidence-based support to help people with suspected or confirmed lung cancer to stop smoking. This may also include referral pathways to evidence-based stop smoking support.
Healthcare professionals (such as GPs, pharmacists, clinical nurse specialists, consultants and radiographers) provide advice to adults with suspected or confirmed lung cancer who smoke about why it is important to stop smoking. They arrange for them to access evidence-based stop smoking support if they want to stop.
Commissioners (such as clinical commissioning groups, NHS England and local authorities) ensure that they commission services which provide evidence-based stop smoking support to adults with suspected or confirmed lung cancer who smoke.
Adults with suspected or confirmed lung cancer who smoke are told that it is important to stop smoking to avoid complications during treatment and prevent other smoking-related illnesses. They are told that stopping smoking may improve how long they live, and they are given help if they want to give up.

Source guidance

Definitions of terms used in this quality statement

Suspected lung cancer
Adults with symptoms and signs of lung cancer who are referred for investigation.
[Expert opinion]
Evidence-based stop smoking support
The following interventions should be available:
  • behavioural support (individual and group)
  • bupropion (see information on bupropion hydrochloride in the British national formulary)
  • nicotine replacement therapy – short and long acting
  • varenicline (see information on varenicline in the British national formulary)
  • very brief advice.
[NICE’s guideline on stop smoking interventions and services, recommendation 1.3.1 and terms used in this guideline and NICE’s guideline on lung cancer, recommendation 1.4.3]

Equality and diversity considerations

Information about stopping smoking should be in a format that suits the person’s needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate. People should have access to an interpreter or advocate if needed. For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Lung cancer clinical nurse specialist

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

Quality statement

Adults with suspected or confirmed lung cancer have access to a named lung cancer clinical nurse specialist.

Rationale

Lung cancer clinical nurse specialists can provide specialist guidance and support at all stages of care and treatment for adults with lung cancer and their family and carers. They can act as the key worker, coordinating care between secondary and primary care and providing continuity. Having a named clinical nurse specialist will ensure that adults with lung cancer can access advice and support whenever they need it, helping to improve their quality of life and health outcomes.

Quality measures

Structure
a) Evidence of the availability of clinical nurse specialists who specialise in the care and support of adults with lung cancer.
Data source: Local data collection, for example, workforce plans or staff rotas. Clinical advice to cancer alliances for the commissioning of the whole lung cancer pathway (Lung Cancer Clinical Expert Group, 2017) recommends 1 whole-time equivalent nurse for an annual caseload of 80 new patients.
b) Evidence of local arrangements to ensure that adults with lung cancer know how to contact the lung cancer clinical nurse specialist between hospital visits.
Data source: Local data collection, for example, service protocols and information on how to contact a clinical nurse specialist.
Process
a) Proportion of adults with lung cancer who had a lung cancer clinical nurse specialist present at diagnosis.
Numerator – the number in the denominator who had a lung cancer clinical nurse specialist present at diagnosis.
Denominator – the number of adults with lung cancer.
Data source: Royal College of Physicians National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on people who had a lung cancer clinical nurse specialist present for diagnosis.
b) Proportion of adults with lung cancer who have had assessment by a lung cancer clinical nurse specialist.
Numerator – the number in the denominator who have had assessment by a lung cancer clinical nurse specialist.
Denominator – the number of adults with lung cancer.
Data source: Royal College of Physicians National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on people assessed by a lung cancer clinical nurse specialist.
c) Proportion of adults with lung cancer who were given the name of a lung cancer clinical nurse specialist who would support them.
Numerator – the number in the denominator who were given the name of a lung cancer clinical nurse specialist who would support them.
Denominator – the number of adults with lung cancer.
Data source: Local data collection, for example, audit of patient records. Quality Health National Cancer Patient Experience Survey includes data on people with lung cancer who were given the name of a clinical nurse specialist who would support them through their treatment.
Outcome
a) Proportion of adults with lung cancer who are satisfied with the support provided by a lung cancer clinical nurse specialist.
Numerator – the number in the denominator who are satisfied with the support provided by a lung cancer clinical nurse specialist.
Denominator – the number of adults with lung cancer.
Data source: Local data collection, for example, a survey of adults with lung cancer. Quality Health National Cancer Patient Experience Survey includes data on ease of contacting a clinical nurse specialist for people with lung cancer receiving hospital treatment.
b) Health-related quality of life for adults with lung cancer.
Data source: Local data collection, for example, a survey of adults with lung cancer or their families and carers including patient-reported outcome measure.

What the quality statement means for different audiences

Service providers (such as secondary and tertiary care) ensure that lung cancer clinical nurse specialists are available to support adults with suspected or confirmed lung cancer throughout their care. Providers ensure that processes are in place for adults with lung cancer to be supported by a lung cancer clinical nurse specialist at diagnosis and for them to have regular assessments with a lung cancer clinical nurse specialist at key points in their care.
Healthcare professionals (such as members of the lung cancer multidisciplinary team) ensure that adults with suspected or confirmed lung cancer know how to contact a lung cancer clinical nurse specialist between hospital visits. Healthcare professionals share information with the lung cancer clinical nurse specialist to allow them to coordinate care for adults with lung cancer. Lung cancer clinical nurse specialists provide support and information to adults with lung cancer and carry out assessments at key points of care.
Commissioners (clinical commissioning groups) commission services with enough clinical nurse specialists with expertise in lung cancer to support all adults with lung cancer throughout all stages of care.
Adults with lung cancer can contact a clinical nurse specialist (a nurse experienced in treating lung cancer) for information, advice and support throughout their care.

Source guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendations 1.2.2, 1.3.33 and 1.6.3.

Definitions of terms used in this quality statement

Suspected lung cancer
Adults with symptoms and signs of lung cancer who are referred for investigation.
[Expert opinion]
Lung cancer clinical nurse specialist
This can include surgical or oncology lung cancer clinical nurse specialists as well as palliative care clinical nurse specialists, depending on the stage of care.
[Expert opinion]

Equality and diversity considerations

Lung cancer clinical nurse specialists should ensure that people are provided with information that they can easily read and understand themselves, or with support, so that they can communicate effectively with health and care services. Information should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate. People should have access to an interpreter or advocate if needed. For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Investigations

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

Quality statement

Adults with lung cancer being considered for treatment with curative intent have investigations to accurately determine diagnosis and stage, and to assess lung function.

Rationale

Undergoing treatment with curative intent when lung cancer has already spread can reduce quality of life without increasing life expectancy. It is important that adults who are being considered for treatment with curative intent have accurate diagnosis and staging. This will ensure that the most appropriate treatment is provided. Risk assessment for people being considered for treatment with curative intent should include assessment of lung function because this is a good predictor of treatment outcomes.

Quality measures

Structure
a) Evidence of local processes to record investigations to accurately determine diagnosis and stage and to assess lung function, for adults with lung cancer who are being considered for treatment with curative intent.
Data source: Local data collection, for example, local protocols.
b) Evidence of availability of positron-emission tomography CT (PET-CT) for adults with lung cancer who are being considered for treatment with curative intent.
Data source: Local data collection, for example, waiting times for PET-CT (including results) for adults with lung cancer. NHS England’s Implementing a timed lung cancer diagnostic pathway indicates that investigations should be complete by day 14 in the 28-day pathway.
c) Evidence of availability of brain imaging for adults with non-small-cell lung cancer stage II or III who are being considered for treatment with curative intent.
Data source: Local data collection, for example, access to MRI and waiting times for brain imaging (including results) for adults with non-small-cell lung cancer. NHS England’s Implementing a timed lung cancer diagnostic pathway indicates that investigations should be complete by day 14 in the 28-day pathway.
Process
a) Proportion of adults with lung cancer treated with curative intent who had PET-CT before starting treatment.
Numerator – the number in the denominator who had PET-CT before starting treatment.
Denominator – the number of adults with lung cancer treated with curative intent.
Data source: Royal College of Physicians National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on people receiving a PET-CT scan before surgery or radical radiotherapy.
b) Proportion of adults with non-small-cell lung cancer stage II or III treated with curative intent who had brain imaging before starting treatment.
Numerator – the number in the denominator who had brain imaging before starting treatment.
Denominator – the number of adults with non-small-cell lung cancer stage II or III treated with curative intent.
Data source: Local data collection, for example, audit of patient records.
c) Proportion of adults with non-small-cell lung cancer treated with curative intent who had spirometry and transfer factor (TLCO) before starting treatment.
Numerator – the number in the denominator who had spirometry and TLCO before starting treatment.
Denominator – the number of adults with non-small-cell lung cancer treated with curative intent.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset includes data on diffusion capacity or TLCO, and forced expiratory volume (FEV1). Royal College of Physicians National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on completeness for FEV1 and FEV1% predicted for people with stage I or II lung cancer and performance status 0 to 1.
d) Proportion of adults with lung cancer who had clinical stage and performance status recorded.
Numerator – the number in the denominator who had clinical stage and performance status recorded.
Denominator – the number of adults with lung cancer.
Data source: Royal College of Physicians National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on valid performance status and stage.
Outcome
1-year survival rate for adults with lung cancer treated with curative intent.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.

What the quality statement means for different audiences

Service providers (such as secondary and tertiary care) ensure that processes are in place for adults with lung cancer who are being considered for treatment with curative intent to have investigations to accurately determine diagnosis and stage, and to check lung function. Providers ensure that adults with lung cancer do not start treatment with curative intent until the results of PET-CT, brain imaging and lung function (if relevant) are available. Providers follow the NHS England lung cancer diagnostic pathway to ensure investigations are timely and do not lead to treatment being delayed.
Healthcare professionals (such as consultants, clinical nurse specialists and consultant radiographers) arrange for adults with lung cancer who are being considered for treatment with curative intent to have investigations to accurately determine diagnosis and stage, and to check lung function. Healthcare professionals give people information about the purpose of the investigations, and discuss the results with them, including what they might mean for their treatment.
Commissioners (such as clinical commissioning groups) commission services that ensure adults with lung cancer who are being considered for treatment with curative intent have investigations to accurately determine diagnosis and stage, and to check lung function. Commissioners ensure that providers have the equipment and capacity to carry out PET-CT and brain imaging without delaying the start of treatment with curative intent.
Adults with lung cancer who may be able to have treatment to cure their cancer have scans to confirm the diagnosis and stage of the cancer, and tests to check how well their lungs are working. The results will help to identify the most suitable treatment.

Source guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendations 1.3.4, 1.3.18, 1.3.19, 1.3.22, 1.3.23, 1.3.24, 1.3.25 and 1.4.13.

Definitions of terms used in this quality statement

Investigations to accurately determine diagnosis and stage, and to assess lung function
Investigations should include:
  • PET-CT
  • stage-specific brain imaging for people with non-small-cell lung cancer
    • no brain imaging for people with stage I
    • contrast-enhanced brain CT for people with stage II
    • contrast-enhanced brain MRI for people with stage III
  • spirometry and TLCO for people with non-small-cell lung cancer
[NICE’s guideline on lung cancer, recommendations 1.3.4, 1.3.23, 1.3.24, 1.3.25 and 1.4.13]
Treatment with curative intent for lung cancer
There are a variety of treatment options and combinations of treatment that aim to remove the tumour and effect a cure for adults with lung cancer. These include: surgery, radiotherapy, chemotherapy and chemoradiotherapy. The approach to treatment will depend on the type of lung cancer, the clinical stage of the tumour, the person’s performance status, comorbidities and the person’s choice.
[NICE’s guideline on lung cancer and expert opinion]

Treatment with curative intent

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

Quality statement

Adults with non-small-cell lung cancer stage I or II and good performance status have treatment with curative intent.

Rationale

Treatment with curative intent improves survival. There are a variety of options for treatment with curative intent in adults with stage I or II non-small-cell lung cancer who are well enough. Decisions about these treatment options should be taken at multidisciplinary team meetings that include all specialist core members. Adults with lung cancer should be involved in deciding which treatment or combinations of treatment best suit them.

Quality measures

Structure
a) Evidence that lung cancer multidisciplinary team meetings include all specialist core members.
Data source: Local data collection, such as attendance monitoring for lung cancer multidisciplinary team meetings.
b) Evidence of local processes for discussing options for treatment with curative intent with adults with stage I or II non-small-cell lung cancer and good performance status.
Data source: Local data collection, such as local clinical protocols and patient information resources.
c) Evidence of local arrangements and written clinical protocols to ensure that adults with non-small-cell lung cancer stage I or II and good performance status have treatment with curative intent.
Data source: Local data collection, such as local clinical protocols.
Process
Proportion of adults with non-small-cell lung cancer stage I or II and good performance status who have treatment with curative intent.
Numerator – the number in the denominator who have treatment with curative intent.
Denominator – the number of adults with non-small-cell lung cancer stage I or II and good performance status.
Data source: Royal College of Physicians National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on people with non-small-cell lung cancer stage I or II and performance status 0 to 2 receiving treatment with curative intent.
Outcome
a) Proportion of adults with non-small-cell lung cancer stage I or II and good performance status who are satisfied that treatment options were explained to them.
Numerator – the number in the denominator who are satisfied that treatment options were explained to them.
Denominator – the number of adults with non-small-cell lung cancer stage I or II and good performance status.
Data source: Local data collection, for example, a survey of adults with non-small-cell lung cancer or their families and carers.
b) 1-year survival rate for adults with non-small-cell lung cancer stage I or II.
Data source National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.
c) 5-year survival rate for adults with non-small-cell lung cancer stage I or II.
Data source: Local data collection, for example, audit of patient review records.

What the quality statement means for different audiences

Service providers (such as secondary and tertiary care) ensure that lung cancer multidisciplinary team meetings include all specialist core members to support decisions on treatment for adults with lung cancer. Service providers ensure that staff are trained to discuss the risks and benefits of treatment options with adults with stage I or II non-small-cell lung cancer and good performance status and to support shared decision making. Service providers ensure that all treatment options are available.
Healthcare professionals (such as members of lung cancer multidisciplinary teams) attend lung cancer multidisciplinary team meetings and advise on treatment options for adults with non-small-cell lung cancer. Healthcare professionals discuss the risks and benefits of treatment options with adults with stage I or II non-small-cell lung cancer and good performance status and support them to make decisions about treatment.
Commissioners (such as clinical commissioning groups) commission services that ensure that adults with non-small-cell lung cancer stage I or II and good performance status can receive treatment with curative intent. Commissioners ensure that services have expertise to support decisions about optimal treatment for adults with non-small-cell lung cancer and that all suitable treatment options are available.
Adults who are fit and have early-stage non-small-cell lung cancer are offered treatment that may cure their cancer. They discuss treatment options with a healthcare professional who explains the risks and benefits of the different options.

Source guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendations 1.4.20, 1.4.21, 1.4.24, 1.4.27, 1.4.34 and 1.4.35

Definitions of terms used in this quality statement

Treatment with curative intent for non-small-cell lung cancer
There are a variety of options for treatment with curative intent for adults with stage I or II non-small-cell lung cancer and good performance status. The approach to treatment will depend on the clinical stage of the tumour, the person’s performance status, comorbidities and personal choice. The following options should be available, and the risks and benefits of the options that are suitable should be discussed with the person:
  • surgery – lobectomy, sublobar resection, bronchoangioplastic surgery, bilobectomy or pneumonectomy
  • radiotherapy – stereotactic ablative radiotherapy (SABR) or conventional or hyperfractionated radiotherapy
  • chemoradiotherapy
  • multimodality treatment (surgery, radiotherapy and chemotherapy in any combination)
[NICE’s guideline on lung cancer, recommendations 1.4.20, 1.4.21, 1.4.24, 1.4.27, 1.4.32, 1.4.33, 1.4.34 and 1.4.35]
Good performance status
A measure of how well a patient can perform ordinary tasks and carry out daily activities. A good performance status in this context is defined as a World Health Organization (WHO) score of 0 to 2:
  • 0, able to carry out all normal activity without restriction
  • 1, restricted in strenuous activity but ambulatory and able to carry out light work
  • 2, ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours.
[NICE’s 2011 full guideline on lung cancer, glossary (appendix 6) and Royal College of Physicians National Lung Cancer Audit]

Equality and diversity considerations

Healthcare professionals should ensure that people with non-small-cell lung cancer are not excluded from treatment with curative intent because of their age. They should support older people to consider all the treatment options carefully before deciding which option suits them best.

Tissue sampling

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

Quality statement

Adults with non-small-cell lung cancer stage III or IV who are having tissue sampling, have samples taken that are suitable for pathological diagnosis and assessment of predictive biomarkers.

Rationale

Drug treatments for non-small-cell lung cancer work best if they are targeted according to the histological sub-type and predictive biomarkers of the tumour. Obtaining a pathological diagnosis and assessment of predictive biomarkers for a lung tumour in people with good performance status ensures that the most appropriate treatment regimen is offered. It is important that samples taken for diagnosis and staging yield enough material for pathology tests and immunohistochemical and/or genetic analysis. This will reduce delays to treatment by minimising the need for further sampling before making treatment decisions.

Quality measures

Structure
a) Evidence of the availability of radiologists and respiratory specialists experienced in performing lung biopsies for adults with lung cancer.
Data source: Local data collection, for example, workforce plans or staff rotas.
b) Evidence of local processes to ensure that adults with non-small-cell lung cancer stage III or IV who are having tissue sampling, have samples taken that are suitable for pathological diagnosis and assessment of predictive biomarkers.
Data source: Local data collection, for example, service protocols.
c) Evidence of audit of the local test performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for people with lung cancer.
Data source: Local data collection, for example, audit reports. Specific details of audit for EBUS-TBNA are included in the British Thoracic Society quality standards for diagnostic flexible bronchoscopy in adults (statements 5a and b).
Process
a) Proportion of adults with non-small-cell lung cancer stage III or IV who have a second diagnostic test in order to determine histological sub-type or predictive biomarkers.
Numerator – the number in the denominator who have a second diagnostic test in order to determine histological sub-type or predictive biomarkers.
Denominator – the number of adults with non-small-cell lung cancer stage III or IV.
Data source: Local data collection, for example, audit of patient records. For measurement purposes, this measure aims to identify where suitable samples have not been taken, making it necessary for a second test to be carried out.
b) Proportion of adults with non-small-cell lung cancer stage III or IV for whom the reported tumour sub-type is ‘not otherwise specified’.
Numerator – the number in the denominator for whom the reported tumour sub-type is ‘not otherwise specified’.
Denominator – the number of adults with non-small-cell lung cancer stage III or IV.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset. For measurement purposes, this measure aims to identify where suitable samples have not been taken, resulting in a sub-type ‘not otherwise specified’.
c) Proportion of adults with non-small-cell lung cancer stage III or IV and performance status 0 to 2 who are successfully tested for all relevant biomarkers.
Numerator – the number in the denominator who are successfully tested for all relevant biomarkers.
Denominator – the number of adults with non-small-cell lung cancer stage III or IV and performance status 0 to 2.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset includes data on epidermal growth factor receptor mutational status, ALK fusion status, ROS1 Fusion status and PD-L1 expression.
Outcome
a) Proportion of adults with non-small-cell lung cancer stage III or IV and performance status 0 to 2 who have a pathological diagnosis.
Numerator – the number in the denominator who have a pathological diagnosis.
Denominator – the number of adults with non-small-cell lung cancer stage III or IV and performance status 0 to 2.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.
b) 1-year survival rate for adults with non-small-cell lung cancer stage III or IV.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.

What the quality statement means for different audiences

Service providers (such as secondary and tertiary care) ensure that adults with non-small-cell lung cancer stage III or IV who are having tissue sampling, have samples taken that are suitable for pathological diagnosis and assessment of predictive biomarkers. Providers ensure that lung cancer multidisciplinary teams include radiologists and respiratory specialists experienced in performing lung biopsies for adults with lung cancer. Providers also audit local test performance for EBUS-TBNA and EUS-FNA to assess the sensitivity of the procedures and the suitability of samples.
Healthcare professionals (such as respiratory specialists and radiologists) take tissue samples from adults with non-small-cell lung cancer stage III or IV that are suitable for pathological diagnosis and assessment of predictive biomarkers.
Commissioners (such as clinical commissioning groups) commission services that ensure that adults with non-small-cell lung cancer stage III or IV have tissue samples taken that are suitable for pathological diagnosis and assessment of predictive biomarkers.
Adults with advanced non-small-cell lung cancer have tissue samples taken that give enough information for a complete diagnosis and to guide treatment options.

Source guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendation 1.3.11

Definitions of terms used in this quality statement

Samples suitable for pathological diagnosis and assessment of predictive biomarkers
Providing there is no risk to the person, tissue samples of sufficient size and quality should be taken to support pathological diagnosis, including tumour sub-typing and assessment of predictive biomarkers. The samples should:
  • allow pathologists to classify non-small-cell lung cancer into squamous cell carcinoma or adenocarcinoma wherever possible
  • support stage-appropriate immunohistochemical and/or genetic analysis to detect specific biomarkers that predict whether targeted treatments are likely to be effective, for example, epidermal growth factor receptor (EGFR) mutations, anaplastic lymphoma kinase (ALK) gene rearrangement, programmed death-ligand 1 (PD-L1) expression or ROS-1 gene mutation.
[NICE’s 2011 full guideline on lung cancer and expert opinion]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Provide treatment without undue delay for people who have lung cancer that is suitable for radical treatment or chemotherapy, or who need radiotherapy or ablative treatment for relief of symptoms.
For people with stage I-IIa (T1a-T2b, N0, M0) NSCLC who decline lobectomy or in whom it is contraindicated, offer radical radiotherapy with SABR or sublobar resection.
If people do not immediately progress after chemotherapy, see below.
On progression after first-line chemotherapy, see below or offer docetaxel monotherapy.
On progression after atezolizumab combination, see below or offer docetaxel monotherapy.
Atezolizumab plus bevacizumab, carboplatin and paclitaxel is recommended as an option for metastatic non-squamous NSCLC in adults:
  • who have not had treatment for their metastatic NSCLC before and whose PD-L1 tumour proportion score is between 0% and 49% or
  • when targeted therapy for EGFR-positive or ALK-positive NSCLC has failed.
It is recommended only if:
  • atezolizumab and bevacizumab are stopped at 2 years of uninterrupted treatment, or earlier if there is loss of clinical benefit (for atezolizumab) or if the disease progresses (for bevacizumab), and
  • the company provides atezolizumab and bevacizumab according to the commercial arrangements.
This recommendation is not intended to affect treatment with atezolizumab plus bevacizumab, carboplatin and paclitaxel that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.
Atezolizumab is recommended as an option for treating locally advanced or metastatic NSCLC in adults who have had chemotherapy (and targeted treatment if they have an EGFR- or ALK-positive tumour), only if:
  • atezolizumab is stopped at 2 years of uninterrupted treatment or earlier if the disease progresses and
  • the company provides atezolizumab with the discount agreed in the patient access scheme.
This recommendation is not intended to affect treatment with atezolizumab that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.
The NICE technology appraisal of bevacizumab for treating EGFR mutation-positive NSCLC was terminated because no evidence submission was received from Roche. Therefore NICE was unable to make a recommendation about the use of this technology in the NHS.
Crizotinib is recommended for use within the Cancer Drugs Fund as an option for treating ROS1-positive advanced NSCLC in adults, only if the conditions in the managed access agreement are followed.
This recommendation is not intended to affect treatment with crizotinib that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.
Erlotinib monotherapy is not recommended for maintenance treatment in people with locally advanced or metastatic NSCLC who have stable disease after platinum-based first-line chemotherapy.
People currently receiving erlotinib monotherapy for maintenance treatment of locally advanced or metastatic NSCLC who have stable disease after platinum-based first-line chemotherapy should have the option to continue treatment until they and their clinician consider it appropriate to stop.
Nivolumab is recommended for use within the Cancer Drugs Fund as an option for treating locally advanced or metastatic non-squamous NSCLC in adults after chemotherapy, only if:
  • their tumours are PD-L1 positive and
  • nivolumab is stopped at 2 years of uninterrupted treatment, or earlier in the event of disease progression, and
  • the conditions in the managed access agreement are followed.
This recommendation is not intended to affect treatment with nivolumab that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.
Nintedanib in combination with docetaxel is recommended, within its marketing authorisation, as an option for treating locally advanced, metastatic or locally recurrent NSCLC of adenocarcinoma histology that has progressed after first-line chemotherapy, only if the company provides nintedanib with the discount agreed in the patient access scheme.
Nivolumab is recommended for use within the Cancer Drugs Fund as an option for treating locally advanced or metastatic squamous NSCLC in adults after chemotherapy, only if:
  • nivolumab is stopped at 2 years of uninterrupted treatment, or earlier in the event of disease progression, and
  • the conditions in the managed access agreement are followed.
This recommendation is not intended to affect treatment with nivolumab that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.
The NICE technology appraisal of paclitaxel as albumin-bound nanoparticles with carboplatin for untreated NSCLC was terminated because no evidence submission was received from Celgene for the technology. Therefore NICE is unable to make a recommendation about the use in the NHS of paclitaxel as albumin-bound nanoparticles with carboplatin for adults with untreated non-small-cell lung cancer when potentially curative surgery or radiation therapy or both are unsuitable.
Pembrolizumab, with carboplatin and paclitaxel, is recommended for use within the Cancer Drugs Fund as an option for untreated metastatic squamous NSCLC in adults only if:
  • pembrolizumab is stopped at 2 years of uninterrupted treatment, or earlier if disease progresses, and
  • the company provides pembrolizumab according to the managed access agreement.
This recommendation is not intended to affect treatment with pembrolizumab, with carboplatin and paclitaxel, that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.
Pembrolizumab, with pemetrexed and platinum chemotherapy is recommended for use within the Cancer Drugs Fund, as an option for untreated, metastatic, non-squamous NSCLC in adults whose tumours have no EGFR- or ALK-positive mutations. It is only recommended if:
  • pembrolizumab is stopped at 2 years of uninterrupted treatment or earlier if disease progresses and
  • the company provides pembrolizumab according to the managed access agreement.
This recommendation is not intended to affect treatment with pembrolizumab with pemetrexed and platinum chemotherapy that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.
Pembrolizumab is recommended as an option for untreated PD-L1-positive metastatic NSCLC in adults whose tumours express PD-L1 (with at least a 50% tumour proportion score) and have no EGFR- or ALK-positive mutations, only if:
  • pembrolizumab is stopped at 2 years of uninterrupted treatment or earlier in the event of disease progression and
  • the company provides pembrolizumab according to the commercial access agreement.
Pembrolizumab is recommended as an option for treating locally advanced or metastatic PD-L1-positive NSCLC in adults who have had at least one chemotherapy (and targeted treatment if they have an EGFR- or ALK-positive tumour), only if:
  • pembrolizumab is stopped at 2 years of uninterrupted treatment and no documented disease progression, and
  • the company provides pembrolizumab in line with the commercial access agreement with NHS England.
This guidance is not intended to affect the position of patients whose treatment with pembrolizumab was started within the NHS before this guidance was published. Treatment of those patients may continue without change to whatever funding arrangements were in place for them before this guidance was published until they and their NHS clinician consider it appropriate to stop.
Pemetrexed is recommended as an option for the maintenance treatment of locally advanced or metastatic non-squamous NSCLC in adults when:
  • their disease has not progressed immediately after 4 cycles of pemetrexed and cisplatin induction therapy
  • their ECOG performance status is 0 or 1 at the start of maintenance treatment and
  • the company provides the drug according to the terms of the commercial access agreement as agreed with NHS England.
When using ECOG performance status, healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect ECOG performance status and make any adjustments they consider appropriate.
This guidance is not intended to affect the position of patients whose treatment with pemetrexed was started within the NHS before this guidance was published. Treatment of those patients may continue without change to whatever funding arrangements were in place for them before this guidance was published until they and their NHS clinician consider it appropriate to stop.
Pemetrexed is recommended as an option for the maintenance treatment of people with locally advanced or metastatic NSCLC other than predominantly squamous cell histology if disease has not progressed immediately following platinum-based chemotherapy in combination with gemcitabine, paclitaxel or docetaxel.
Pemetrexed is not recommended for the treatment of locally advanced or metastatic NSCLC.
People currently receiving pemetrexed should have the option to continue therapy until they and their clinicians consider it appropriate to stop.
Ramucirumab, in combination with docetaxel, is not recommended within its marketing authorisation for treating locally advanced or metastatic NSCLC in adults whose disease has progressed after platinum-based chemotherapy.
This guidance is not intended to affect the position of patients whose treatment with ramucirumab was started within the NHS before this guidance was published. Treatment of those patients may continue without change to whatever funding arrangements were in place for them before this guidance was published until they and their NHS clinician consider it appropriate to stop.

Glossary

anaplastic lymphoma kinase
Bispectral Index
(the finding has characteristics that could be caused by many things, including cancer)
endobronchial ultrasound
Eastern Cooperative Oncology Group
electroencephalography
epidermal growth factor receptor
epidermal growth factor receptor tyrosine kinase
endoscopic ultrasound
forced expiratory volume in 1 second
fine needle aspiration
multidisciplinary team
non-small-cell lung cancer
neurotrophic tyrosine receptor kinase
(the continuation of specified symptoms and/or signs beyond a period that would normally be associated with self-limiting problems; the precise period will vary depending on the severity of symptoms and associated features, as assessed by the healthcare professional)
positron emission tomography–computed tomography
stereotactic ablative radiotherapy
stereotactic body irradiation
small-cell lung cancer
transbronchial needle aspiration
carbon monoxide lung transfer factor
(symptoms or signs that have not led to a diagnosis being made by the healthcare professional in primary care after initial assessment; including history, examination and any primary care investigations)

Paths in this pathway

Pathway created: March 2012 Last updated: July 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

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