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Lung cancer

About

What is covered

This interactive flowchart 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 interactive flowchart

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.
16 July 2013 SonoVue for contrast-enhanced ultrasound imaging of the liver (NICE diagnostics guidance 5) added to CT scan.
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 interactive flowchart 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 interactive flowchart

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.
16 July 2013 SonoVue for contrast-enhanced ultrasound imaging of the liver (NICE diagnostics guidance 5) added to CT scan.
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

Quality statements

Public awareness

This quality statement is taken from the lung cancer in adults 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.

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 guidance

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

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.

Appointment with a cancer specialist

This quality statement is taken from the lung cancer in adults 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 and people aged 40 and over with unexplained haemoptysis are offered an appointment to see a cancer specialist within 2 weeks.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with chest X-ray results suggesting lung cancer and people aged 40 and over with unexplained haemoptysis are seen by a cancer specialist within 2 weeks.
Process
a) Proportion of people with chest X-ray results that suggest lung cancer who are seen by a cancer specialist within 2 weeks.
Numerator – the number of people in the denominator who are seen by a cancer specialist within 2 weeks.
Denominator – the number of people with chest X-ray results that suggest lung cancer.
b) Proportion of people aged 40 and over with unexplained haemoptysis who are seen by a cancer specialist within 2 weeks.
Numerator – the number of people in the denominator who are seen by a cancer specialist within 2 weeks.
Denominator – the number people aged 40 and over with unexplained haemoptysis.

What the quality statement means for each audience

Service providers ensure there are systems in place for people with chest X-ray results that suggest lung cancer and people aged 40 and over with unexplained haemoptysis to be seen by a cancer specialist within 2 weeks.
Healthcare professionals refer people with chest X-ray results that suggest lung cancer and people aged 40 and over with unexplained haemoptysis for an appointment with a cancer specialist in cancer within 2 weeks.
Commissioners ensure they commission services to provide an appointment to see a cancer specialist within 2 weeks for people with chest X-ray findings that suggest lung cancer and people aged 40 and over with unexplained haemoptysis.
People with signs of possible lung cancer on a chest X ray and people aged 40 and over who are coughing up blood (and there is no other cause) are offered an appointment to see a cancer specialist within 2 weeks.

Source guidance

Suspected cancer: recognition and referral (2015 updated 2017) NICE guideline NG12, recommendation 1.1.1

Data source

Structure
Local data collection.
Process
Local data collection. Data on cancer waiting times are available via NHS England.

Chest X-ray report

This statement was removed from the quality standard in March 2019. This was because the recommendations from NICE in this area have changed.

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 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.

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 guidance

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

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 guidance

Improving supportive and palliative care for adults with cancer (2004) NICE guideline CSG4, 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 in adults 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 guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendations 1.3.1–1.3.28

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.

Tissue diagnosis

This quality statement is taken from the lung cancer in adults 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.

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 guidance

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 statement was removed from the quality standard in March 2019. This was because the recommendations from NICE in this area have changed.

Access to specialist assessment

This quality statement is taken from the lung cancer in adults 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.

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 guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendations 1.4.19 and 1.4.34

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 in adults 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 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 are assessed for radiotherapy with curative intent by a clinical oncologist specialising in thoracic oncology.
Process
Proportion of people with lung cancer 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.

What the quality statement means for each audience

Service providers ensure there are systems in place for people with lung cancer 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 for radiotherapy with curative intent.
Commissioners ensure they commission services for people with lung cancer to be assessed for radiotherapy with curative intent by a clinical oncologist specialising in thoracic oncology.
People with lung cancer 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 guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendation 1.4.19

Data source

Structure
Local data collection.
Process
Local data collection.

Optimal radiotherapy

This quality statement is taken from the lung cancer in adults 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 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 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 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.
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 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 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 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 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 guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendations 1.4.25–1.4.29

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

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 in adults 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 are offered systemic therapy in accordance with NICE guidance, that is directed by histology, molecular markers and PD-L1 expression.

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 are offered systemic therapy in accordance with NICE guidance, that is directed by histology, molecular markers and PD-L1 expression.
Process
Proportion of people with stage IIIB or IV non‑small‑cell lung cancer who receive systemic therapy in accordance with NICE guidance, that is directed by histology, molecular markers and PD-L1 expression.
Numerator – the number of people in the denominator who receive systemic therapy in accordance with NICE guidance, that is directed by histology, molecular markers and PD-L1 expression.
Denominator – the number of people with stage IIIB or IV non‑small‑cell lung cancer.

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 to be offered systemic therapy in accordance with NICE guidance, that is directed by histology, molecular markers and PD-L1 expression.
Healthcare professionals offer systemic therapy to people with stage IIIB or IV non‑small‑cell lung cancer in accordance with NICE guidance, that is directed by histology, molecular markers and PD-L1 expression.
Commissioners ensure they commission services for people with stage IIIB or IV non‑small‑cell lung cancer to be offered systemic therapy in accordance with NICE guidance, that is directed by histology, molecular markers and PD-L1 expression.
People with advanced (stage IIIB or IV) non-small-cell lung cancer are offered chemotherapy in accordance with NICE guidance, determined by the type of the tumour (histology) and other laboratory tests.

Source guidance

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.
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

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 are offered systemic therapy in accordance with the NICE guideline on lung cancer, recommendations 1.4.45–1.4.51.

Small-cell lung cancer

This quality statement is taken from the lung cancer in adults 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.

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 guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendation 1.4.52

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 the NICE guideline on lung cancer, recommendations 1.4.53–1.4.57 and 1.4.59–1.4.67, and NICE technology appraisal guidance on topotecan for the treatment of relapsed small-cell lung cancer.

Optimal follow-up regime

This quality statement is taken from the lung cancer in adults 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.

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 guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendations 1.6.1 and 1.6.2

Data source

Structure
Local data collection.
Process
a) and b) Local data collection.
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 in adults 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.

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 guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendations 1.5.1–1.5.19

Data source

Structure
Local data collection.
Process
a) and b) Local data collection.

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

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.
See also what NICE says on medicines optimisation.
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 the NICE technology appraisal guidance on pemetrexed maintenance after pemetrexed and pemetrexed maintenance after other platinum doublet chemotherapy (see below).
On progression after first-line chemotherapy, see the NICE technology appraisal guidance on atezolizumab, nivolumab, pembrolizumab and nintedanib with docetaxel (see below) or offer docetaxel monotherapy.
The following recommendations are from NICE technology appraisal guidance on atezolizumab for treating locally advanced or metastatic non-small-cell lung cancer after chemotherapy.
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.
NICE has written information for the public on atezolizumab.
The following recommendations are from NICE technology appraisal guidance on crizotinib for treating ROS1-positive advanced non-small-cell lung cancer.
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.
NICE has written information for the public on crizotinib.
The following recommendation is from NICE technology appraisal guidance on nintedanib for previously treated locally advanced, metastatic, or locally recurrent non-small-cell lung cancer.
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.
NICE has written information for the public on nintedanib.
The following recommendation is from NICE technology appraisal guidance on nivolumab for previously treated non-squamous non-small-cell lung cancer.
Nivolumab is recommended for use within the Cancer Drugs Fund as an option for treating locally advanced or metastatic non-squamous non-small-cell lung cancer 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.
NICE has written information for the public on nivolumab for previously treated non-squamous non-small-cell lung cancer.
The following recommendations are from NICE technology appraisal guidance on nivolumab for previously treated squamous non-small-cell lung cancer.
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.
NICE has written information for the public on nivolumab.
The following recommendations are from NICE technology appraisal guidance on pembrolizumab for treating PD-L1-positive non-small-cell lung cancer after chemotherapy.
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.
NICE has written information for the public on pembrolizumab.
The following recommendations are from NICE technology appraisal guidance on pembrolizumab for untreated PD-L1-positive metastatic non-small-cell lung cancer.
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 epidermal growth factor receptor- or anaplastic lymphoma kinase-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.
NICE has written information for the public on pembrolizumab.
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.
NICE has written information for the public on pembrolizumab with pemeterexed and platinum chemotherapy.
The following recommendations are from NICE technology appraisal guidance on pemetrexed maintenance treatment for non-squamous non-small-cell lung cancer after pemetrexed and cisplatin.
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.
NICE has written information for the public on pemetrexed maintenance after pemetrexed and cisplatin.
The following recommendation is from NICE technology appraisal guidance on pemetrexed for the maintenance treatment of non-small-cell lung cancer.
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.
NICE has written information for the public on pemetrexed maintenance after other platinum doublet chemotherapy.
The following recommendations are from NICE technology appraisal guidance on ramucirumab for previously treated locally advanced or metastatic non-small-cell lung cancer.
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.
NICE has written information for the public on ramucirumab.
The following recommendations are from NICE technology appraisal guidance on erlotinib monotherapy for maintenance treatment of non-small-cell lung cancer.
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.
NICE has written information for the public on erlotinib.
The following recommendations are from NICE technology appraisal guidance on pemetrexed for the treatment of non-small-cell lung cancer.
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.
NICE has written information for the public on pemetrexed.
The NICE technology appraisal of bevacizumab for treating EGFR mutation-positive non-small-cell lung cancer 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.
The NICE technology appraisal of paclitaxel as albumin-bound nanoparticles with carboplatin for untreated non-small-cell lung cancer 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.

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
(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: March 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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