Clinical Guideline 24
February 2005

Developed by the National Collaborating Centre for
Acute Care
Lung cancer

The diagnosis and treatment of lung cancer
Clinical Guideline 24
Lung cancer: the diagnosis and treatment of lung cancer

Issue date: February 2005

This document, which contains the Institute's full guidance on lung cancer, is available from
the NICE website (www.nice.org.uk/CG024NICEguideline).
An abridged version of this guidance (a 'quick reference guide') is also available from the
NICE website (www.nice.org.uk/CG024quickrefguide). Printed copies of the quick reference
guide can be obtained from the NHS Response Line: telephone 0870 1555 455 and quote
reference number N0825. The distribution list for the quick reference guide can be found at
www.nice.org.uk/CG024distributionlist
Information for the Public is available from the NICE website
(www.nice.org.uk/CG024publicinfo) or from the NHS Response Line (quote reference number
N0826 for a version in English and N0827 for a version in English and Welsh).
This guidance is written in the following context:

1.3 Staging 12
1.4 Surgery with curative intent for patients with NSCLC 14
1.5 Radical radiotherapy alone for treatment of NSCLC 15
1.6 Chemotherapy for patients with NSCLC 15
1.7 Combination treatment for NSCLC 16
1.8 Treatment of small-cell lung cancer 17
1.9 Palliative interventions and supportive and palliative care 18
1.10 Service organisation 20
2 Notes on the scope of the guidance 22
3 Implementation in the NHS 22
4 Research recommendations 24
5 Other versions of this guideline 26
6 Related NICE guidance 27
7 Review date 27
Appendix A: Grading scheme 28
Appendix B: The Guideline Development Group 31
Appendix C: The Guideline Review Panel 34
Appendix D: Technical detail on the criteria for audit 35
Appendix E: Staging classification and performance status scales 37
Appendix F: Treatment matrix for non-small-cell lung cancer 41 NICE Guideline – lung cancer 4
Introduction
In England and Wales, nearly 29,000 deaths were attributed to lung cancer in
2002. Lung cancer is the most common cause of cancer death for men, who
account for 60% of lung cancer cases. In women, lung cancer is the second
most common cause of cancer death after breast cancer.
Survival rates for lung cancer are very poor. In England, for patients
diagnosed between 1993 and 1995 and followed up to 2000, 21.4% of men

people who do not speak or read English.
Unless specifically excluded by the patient, carers and relatives should have
the opportunity to be involved in decisions about the patient’s care and
treatment.
Carers and relatives should also be provided with the information and support
they need.

NICE Guideline – lung cancer 6
Key priorities for implementation The following recommendations have been identified as priorities for

eligible patients. NICE Guideline – lung cancer 7
Radical radiotherapy alone for treatment of non-small-cell lung cancer
• Patients with stage I or II non-small-cell lung cancer (NSCLC) who are
medically inoperable but suitable for radical radiotherapy should be offered
the continuous hyperfractionated accelerated radiotherapy (CHART)
regimen.

they are based on both diagnostic and effectiveness evidence. A summary of
the evidence on which the guidance is based is provided in the full guideline
(see Section 5).
The development of this guideline for England and Wales coincided with the
review by the Scottish Intercollegiate Guidelines Network (SIGN) of its lung
cancer guideline for Scotland. To minimise duplication of effort, elements of
the systematic review for this guideline were shared between the NICE
guideline development group and the guideline development group working
on the SIGN guideline.

Abbreviations
CHART
CT
DS
FDG
GP
GPP
MDT
MRI
NSCLC
PET
SCLC
SIGN

Continuous hyperfractionated accelerated radiotherapy
Computed tomography
Diagnostic studies

• any of the following unexplained or persistent (that is, lasting
more than 3 weeks) symptoms or signs:
- cough
- chest/shoulder pain
- dyspnoea
- weight loss
- chest signs
- hoarseness
- finger clubbing
- features suggestive of metastasis from a lung cancer (for
example, in brain, bone, liver or skin)
- cervical/supraclavicular lymphadenopathy.

NICE Guideline – lung cancer 10
1.1.5 If a chest X-ray or chest computed tomography (CT) scan suggests
lung cancer (including pleural effusion and slowly resolving
consolidation), patients should be offered an urgent referral to a
member of the lung cancer multidisciplinary team (MDT), usually a
chest physician. D
1.1.6 If the chest X-ray is normal but there is a high suspicion of lung
cancer, patients should be offered urgent referral to a member of
the lung cancer MDT, usually the chest physician. D
1.1.7 Patients should be offered an urgent referral to a member of the
lung cancer MDT, usually the chest physician, while awaiting the
result of a chest X-ray, if any of the following are present: D
• persistent haemoptysis in smokers/ex-smokers older than 40
years
• signs of superior vena caval obstruction (swelling of the
face/neck with fixed elevation of jugular venous pressure)
• stridor.

taken from the metastatic site if this can be achieved more easily
than from the primary site. D(GPP)
1.2.9 An
18
F-deoxyglucose positron emission tomography (FDG-PET)
scan should be performed to investigate solitary pulmonary nodules
in cases where a biopsy is not possible or has failed, depending on
nodule size, position and CT characterisation. C; B(DS) NICE Guideline – lung cancer 12

1.3 Staging
1.3.1 Non-small-cell lung cancer
1.3.1.1 In the assessment of mediastinal and chest wall invasion:
• CT alone may not be reliable B(DS)
• other techniques such as ultrasound should be considered
where there is doubt D(GPP)
• surgical assessment may be necessary if there are no
contraindications to resection. D(GPP)
1.3.1.2 Magnetic resonance imaging (MRI) should not routinely be
performed to assess the stage of the primary tumour (T-stage; see
Appendix E) in NSCLC. C(DS)
1.3.1.3 MRI should be performed, where necessary to assess the extent of
disease, for patients with superior sulcus tumours. B(DS)
1.3.1.4 Every cancer network should have a system of rapid access to
FDG-PET scanning for eligible patients. D(GPP)
1.3.1.5 Patients who are staged as candidates for surgery on CT should
have an FDG-PET scan to look for involved intrathoracic lymph
nodes and distant metastases. A(DS)

1.3.1.13 An X-ray should be performed in the first instance for patients with
localised signs or symptoms of bone metastasis. If the results are
negative or inconclusive, either a bone scan or an MRI scan should
be offered. D(GPP)
1.3.2 Small-cell lung cancer (SCLC)
1.3.2.1 SCLC should be staged by a contrast-enhanced CT scan of the
patient’s chest, liver and adrenals and by selected imaging of any
symptomatic area. D(GPP)

NICE Guideline – lung cancer 14
1.4 Surgery with curative intent for patients with NSCLC
A matrix summarising the treatment of NSCLC can be found in Appendix F.
1.4.1 Surgical resection is recommended for patients with stage I or II
NSCLC who have no medical contraindications and adequate
lung function. D
1.4.2 For patients with stage I or II NSCLC who can tolerate lobar
resection, lobectomy is the procedure of choice. C
1.4.3 Pending further research, patients with stage I or II NSCLC who
would not tolerate lobectomy because of comorbid disease or
pulmonary compromise should be considered for limited resection
or radical radiotherapy. D
1.4.4 For all patients with stage I or II NSCLC undergoing surgical
resection – usually a lobectomy or a pneumonectomy – clear
surgical margins should be the aim. D(GPP)
1.4.5 Sleeve lobectomy offers an acceptable alternative to
pneumonectomy for patients with stage I or II NSCLC who have an
anatomically appropriate (central) tumour. This has the advantage
of conserving functioning lung. C
1.4.6 For patients with T3 NSCLC with chest wall involvement who are
undergoing surgery, complete resection of the tumour should be the

in 20 fractions over 4 weeks should be offered. D(GPP)
1.6 Chemotherapy for patients with NSCLC
A matrix summarising the treatment of NSCLC can be found in Appendix F.
1.6.1 Chemotherapy should be offered to patients with stage III or IV
NSCLC and good performance status (WHO 0, 1 or a Karnofsky
score of 80–100), to improve survival, disease control and
quality of life. A

NICE Guideline – lung cancer 16
1.6.2 Chemotherapy for advanced NSCLC should be a combination of a
single third-generation drug (docetaxel, gemcitabine, paclitaxel or
vinorelbine) plus a platinum drug. Either carboplatin or cisplatin may
be administered, taking account of their toxicities, efficacy and
convenience. D(GPP)
1.6.3 Patients who are unable to tolerate a platinum combination may be
offered single-agent chemotherapy with a third-generation drug. A
1.6.4 Docetaxel monotherapy should be considered if second-line
treatment is appropriate for patients with locally advanced or
metastatic NSCLC in whom relapse has occurred after previous
chemotherapy. A
1.7 Combination treatment for NSCLC
A matrix summarising the treatment of NSCLC can be found in Appendix F.
1.7.1 Patients with stage I, II or IIIA NSCLC who are suitable for resection
should not be offered preoperative chemotherapy unless it is part of
a clinical trial. B
1.7.2 Preoperative radiotherapy is not recommended for patients with
NSCLC who are able to have surgery. A
1.7.3 Postoperative radiotherapy is not recommended for patients with
NSCLC after complete resection. A
1.7.4 Postoperative radiotherapy should be considered after incomplete

considered following chemotherapy if there has been a complete
response at distant sites and at least a good partial response
within the thorax. A
1.8.5 Patients undergoing consolidation thoracic irradiation should
receive a dose in the range of 40 Gy in 15 fractions over 3 weeks to
50 Gy in 25 fractions over 5 weeks. D(GPP)

NICE Guideline – lung cancer 18
1.8.6 Patients with limited disease and complete or good partial response
after primary treatment should be offered prophylactic cranial
irradiation. A
1.8.7 Second-line chemotherapy should be offered to patients at relapse
only if their disease responded to first-line chemotherapy. The
benefits are less than those of first-line chemotherapy. D(GPP)
1.9 Palliative interventions and supportive and palliative care
This section focuses on palliative interventions and supportive and palliative
care for patients with lung cancer and therefore only evidence specific to lung
cancer was reviewed. An absence of evidence does not imply that nothing
can be done to help, and supportive and palliative care multidisciplinary teams
– in particular specialist palliative care teams – have an important role in
symptom control.
1.9.1 Supportive and palliative care of the patient should be provided by
general and specialist palliative care providers in accordance with
the NICE guidance ‘Improving supportive and palliative care for
adults with cancer’ (see Section 6 for details). D(GPP)
1.9.2 Patients who may benefit from specialist palliative care services
should be identified and referred without delay. D(GPP)
1.9.3 External beam radiotherapy should be considered for the relief of
breathlessness, cough, haemoptysis or chest pain. A
1.9.4 Opioids, such as codeine or morphine, should be considered to

1.9.14 Other symptoms, including weight loss, loss of appetite, depression
and difficulty swallowing, should be managed by multidisciplinary
groups that include supportive and palliative care
professionals. D(GPP)
1.9.15 Pleural aspiration or drainage should be performed in an attempt to
relieve the symptoms of a pleural effusion. B

NICE Guideline – lung cancer 20
1.9.16 Patients who benefit symptomatically from aspiration or drainage of
fluid should be offered talc pleurodesis for longer-term benefit. B
1.9.17 For patients with bone metastasis requiring palliation and for whom
standard analgesic treatments are inadequate, single-fraction
radiotherapy should be administered. B
1.9.18 Spinal cord compression is a medical emergency and immediate
treatment (within 24 hours), with corticosteroids, radiotherapy and
surgery where appropriate, is recommended. D
1.9.19 Patients with spinal cord compression should have an early referral
to an oncology physiotherapist and an occupational therapist for
assessment, treatment and rehabilitation. D(GPP)
1.10 Service organisation
1.10.1 All patients with a likely diagnosis of lung cancer should be referred
to a member of a lung cancer MDT (usually a chest physician). D
1.10.2 The care of all patients with a working diagnosis of lung cancer
should be discussed at a lung cancer MDT meeting. D
1.10.3 Early diagnosis clinics should be provided where possible for the
investigation of patients with suspected lung cancer, because they
are associated with faster diagnosis and less patient anxiety. A
1.10.4 All cancer units/centres should have one or more trained lung
cancer nurse specialists to see patients before and after diagnosis,
to provide continuing support, and to facilitate communication

any routine follow-up should not extend beyond 5 years. D
1.10.11 Patients who have had palliative radiotherapy or chemotherapy
should be followed up routinely at 1 month after completion of
treatment. A chest X-ray should be part of the review if clinically
indicated. D
1.10.12 Patients with lung cancer – in particular those with a better
prognosis – should be encouraged to stop smoking. D

NICE Guideline – lung cancer 22
1.10.13 The opinions and experiences of lung cancer patients and carers
should be collected and used to improve the delivery of lung cancer
services. Patients should receive feedback on any action taken as a
result of such surveys. D(GPP)
2 Notes on the scope of the guidance
All NICE guidelines are developed in accordance with a scope document that
defines what the guideline will and will not cover. The scope of this guideline
was established at the start of the development of this guideline, following a
period of consultation; it is available from the NICE website
(www.nice.org.uk/page.aspx?o=32707).
The guideline offers best practice advice on the care of adults who are
suspected of having or are diagnosed with lung cancer. The guideline is
relevant to primary and secondary healthcare professionals who have direct
contact with patients who are suspected of having, or are diagnosed with, lung
cancer, and make decisions about their care.
The guideline covers adults older than 18 years who are suspected of having,
or are diagnosed with, lung cancer.
The guideline does not cover the diagnosis or management of mesothelioma,
lung metastases from cancer arising from outside the lung or the prevention of
lung cancer, nor does it cover children.
3 Implementation in the NHS

recommendations selected as key priorities for implementation. Only two of
these highlighted criteria fall within the LUCADA dataset. Audit criteria,
exceptions and definitions of terms for those recommendations that are not
included in LUCADA are specified.
NICE Guideline – lung cancer 24
4 Research recommendations
The Guideline Development Group has made the following recommendations
for research, on the basis of its review of the evidence. The group regards
these recommendations as the most important research areas to improve
NICE guidance on lung cancer and patient care in the future. The Guideline
Development Group’s full set of research recommendations is detailed in the
full guideline (see Section 5).
4.1 Access to services
4.1.1 Further research is needed into whether the use of low-dose CT in
early diagnosis of patients at high risk of developing lung cancer
has an effect on the mortality of lung cancer. A randomised trial
should compare no intervention with low-dose CT performed at
baseline and then annually for 5 years.
4.1.2 Further research is needed into the symptoms and signs associated
with early- and late-stage lung cancer and the factors associated
with delay in presentation. For patients diagnosed with lung cancer,
analysis should be undertaken of the symptoms at presentation, the
time between onset of symptoms and presentation, the stage at
presentation and the reasons for delay in presentation.
4.2 Chemotherapy for NSCLC
4.2.1 Further research is needed into whether chemotherapy or active
supportive care result in better symptom control, quality of life and