Dr David Baldwin highlights how implementation of the NICE quality standard for lung cancer will help to improve diagnosis and choice of treatment, and hence survival rates

In 2009, 41,428 people were diagnosed with lung cancer in the UK, which represented 13% of all cancers. In 2010 there were 34,859 deaths as a result of lung cancer: 7000 more than for bowel and breast cancer combined. 1 Although survival is beginning to improve, it remains poor and is lower than in other comparable countries.2

Two recent publications reported that people with lung cancer in the UK have lower survival rates than in Sweden, Norway, Australia, and Canada.2,3 The effect was particularly marked in terms of early survival, as most of the excess deaths occurred in the first month after diagnosis.3 This, the authors suggested, is evidence that people in England present later during the course of their illness than in other countries. Furthermore, the National Cancer Intelligence Network’s ‘Routes to diagnosis’ work found that 38% of patients with lung cancer are diagnosed through the emergency route and that these patients have markedly worse outcomes.4 Both early survival rates and the number of patients who present as emergencies are likely to be improved by initiatives that promote early presentation and prompt referral.

Evidence also shows a variation in the standard of care in England: resection rates vary four-fold in cancer networks.5 It was recently shown that patients who are first referred to a thoracic surgical centre rather than a non-surgical centre are 51% more likely to have a resection.6 Findings are similar for other active treatments.7 There is thus a need to improve the standards of care so that the outcomes seen in other countries can be matched or exceeded in England.2

In March 2012, NICE published its quality standard on lung cancer (see Table 1),8 which was developed largely from the recently updated NICE Clinical Guideline 121 (CG121; nice.org.uk/CG121) on the diagnosis and treatment of lung cancer. 9 Both CG121 and the quality standard aim to tackle the aforementioned key issues of late presentation and variations in standards of care. The lung cancer quality standard is also supported by other quality standards on patient experience and
end-of-life care.10,11


Table 1: NICE quality standard for lung cancer8
Number
Quality statements
1
People are made aware of the symptoms and signs of lung cancer through local coordinated public awareness campaigns that result in early presentation.
2
People reporting one or more symptoms suggesting lung cancer are referred within 1 week of presentation for a chest X-ray or directly to a chest physician who is a core member of the lung cancer multidisciplinary team.
3
People with a chest X-ray result suggesting lung cancer have a copy of the radiologist's report sent to and followed up by the lung cancer multidisciplinary team.
4
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.
5
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.
6
People with lung cancer, following initial assessment and computed tomography scan, are offered investigations that give the most information about diagnosis and staging with the least risk of harm.
7
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.
8
People with resectable lung cancer who are of borderline fitness and not initially accepted for surgery are offered the choice of a second surgical opinion, and a multidisciplinary team opinion on non-surgical treatment with curative intent.
9
People with lung cancer are offered assessment for multimodality treatment by a multidisciplinary team comprising all specialist core members.
10
People with lung cancer stage I–III and good performance status who are unable to undergo surgery are assessed for radiotherapy with curative intent by a clinical oncologist specialising in thoracic oncology.
11
People with lung cancer stage I–III and good performance status who are offered radiotherapy with curative intent receive planned treatment techniques that optimise the dose to the tumour while minimising the risks of normal tissue damage.
12
People with stage IIIB or IV non-small-cell lung cancer and eligible performance status are offered systemic therapy (first- and second-line) in accordance with NICE guidance, that is tailored to the pathological sub-type of the tumour and individual predictive factors.
13
People with small-cell lung cancer have treatment initiated within 2 weeks of the pathological diagnosis.
14
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.
15
People with lung cancer have access to all appropriate palliative interventions delivered by expert clinicians and teams.
National Institute for Health and Care Excellence website. Lung cancer for adults quality standard. Available at: www.nice.org.uk/guidance/qualitystandards/lungcancer/home.jsp
Reproduced with kind permission from NICE.

The quality standard for lung cancer in adults

The quality standard comprises 15 quality statements, many of which (statements 3, 4, and 6–13) relate to secondary care; however, it is important for healthcare professionals working in primary care to understand the increasingly complex pathways that patients have to navigate. This can be especially important when patients seek advice because they are not clear about what they should do. Many patients are elderly and/or have co-morbidities, and these patients are often excluded from potentially curative treatments or may benefit from a careful explanation about why they may be helped by what seems to them to be a very complex process.

Awareness and early diagnosis—quality statements 1 and 2

Quality statements 1 and 2 relate directly to primary care and are based on the NICE Clinical Guideline 27 on referral for suspected cancer, which was published in 2005.8,9,12 These statements are supported by the cancer pathway referral system but are critically dependent on an individual GP’s threshold for referral or for requesting a chest X-ray.

Unpublished data indicate wide variations in the use of chest X-rays and rates of rapid-access referral. The difficulty is that many other conditions can cause some of the same symptoms as lung cancer, and these symptoms may recur. The chest X-ray is a good way to detect lung cancer in symptomatic patients13 and should be requested promptly according to the NICE suspected cancer referral guideline (see Box 1).12

Even if a chest X-ray is normal, referral should be prompt when a high index of suspicion remains as a result of:12

  • persistent symptoms
  • heavy smoking
  • older age
  • chronic obstructive pulmonary disease
  • history of other cancer.

Public awareness campaigns are being supported by the Department of Health through the National Awareness and Early Diagnosis Initiative (NAEDI; info.cancerresearchuk.org/spotcancerearly/naedi), which coordinates and provides support to activities and research that promote the earlier diagnosis of cancer. This is a partnership between the Department of Health, the National Cancer Action Team, and Cancer Research UK. 14

Late diagnosis in lung cancer is of key concern, and pilot projects to raise public awareness in the Midlands ran in October 2011 with funding of £1.5 million. This initiative has now been rolled out across England and Wales.15


Box 1: Early diagnosis, awareness, and referral9,12
  • The public needs to be better informed of the symptoms and signs that are characteristic of lung cancer through coordinated campaigning to raise awareness
  • Patients should have the best chance of early diagnosis through prompt attention to warning symptoms and increased awareness.

Referral

  • Urgent referral for a chest X-ray should be offered when a patient presents with:
    • haemoptysis or
    • any of the following unexplained or persistent (lasting longer than 3 weeks) symptoms or signs:
      • cough
      • chest/shoulder pain
      • dyspnoea
      • hoarseness
      • weight loss
      • chest signs
      • finger clubbing
      • features suggestive of metastasis from lung cancer (for example, in the brain, bone, liver, or skin)
      • cervical/supraclavicular lymphadenopathy
  • If a chest X-ray or chest computed tomography 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 MDT, usually a chest physician
  • 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
  • Smokers/ex-smokers older than 40 years with persistent haemoptysis 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
  • Patients should be offered an immediate referral to a member of the lung cancer MDT, usually the chest physician, while awaiting the result of a chest X-ray, if either of the following are present:
    • signs of superior vena cava obstruction (swelling of the face/neck with fixed elevation of jugular venous pressure)
    • stridor.

MDT=multidisciplinary team

Adapted from: National Institute for Health and Care Excellence. The diagnosis and treatment of lung cancer (update). Clinical Guideline 121. London: NICE, 2011. Available at: www.nice.org.uk/guidance/CG121 and National Institute for Health and Care Excellence. Referral guidelines for suspected cancer. Clinical Guideline 27. London: NICE, 2005. Available at: www.nice.org.uk/CG27

Reproduced with kind permission from NICE.

Supporting patients and assessing needs—quality statements 4 and 5

Quality statements 4 and 5 reflect the central role of the lung cancer clinical nurse specialist throughout the pathway and the need for all aspects of the patient’s experience to be assessed.8 These statements are supported by those in the quality standard on patient experience.10

Improving selection for treatment—quality statements 6 and 7

The NICE diagnostic and staging algorithm, which was published in NICE CG121 is shown in Figure 1.9 This was developed following a review of the evidence on the accuracy and safety of investigations, combined with a detailed cost-effectiveness analysis to determine the best sequence of events.9 It is designed to ensure that patients are selected correctly for the most appropriate treatment (statement 6).8 In addition, as modern targeted chemotherapy requires knowledge of tumour subtype and markers that predict response to chemotherapy, diagnostic and staging samples must be of sufficient quality for this purpose (statement 7).8

Figure 1: Diagnostic and staging clinical pathway
Click here to download a PDF of the Diagnostic and staging clinical pathway algorithm.

Improving access to the best treatments—quality statements 8–11

Quality statements 8–11 emphasise the need for good-quality services to ensure that all patients who are potentially suitable for treatment with curative intent have the best chance of being offered such therapy.8 This means a detailed assessment by key members of the lung cancer multidisciplinary team, with the option of a second surgical opinion. When surgery cannot be given, curative radiotherapy should be offered after the patient has been assessed by a clinical oncologist who is skilled in the latest techniques.

Palliative treatments and interventions—quality statements 12–15

For more advanced cases of lung cancer, the best palliative treatments should be offered in line with NICE guidance; this will be a developing area for chemotherapy and targeted therapy as new agents become available (statement 12).8,16-18 Similarly, treatment for small-cell-lung cancer should be in line with NICE guidance, but patients must be offered treatment promptly as this disease is rapidly progressive (statement 13).8,19 Palliative interventions for lung cancer are important as reflected in the NICE guidance for referral of suspected cancer and by quality statement 15, which emphasise that these should be available to patients (see Box 2).8,12

Box 2: Palliative interventions8
  • 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.

National Institute for Health and Care Excellence website. NICE quality standard for lung cancer for adults. Available at: www.nice.org.uk/guidance/qualitystandards/lungcancer/home.jsp

Reproduced with kind permission

Follow up—quality statement 14

Evidence shows that patients who are not given regular follow-up appointments are more likely to use emergency services for uncontrolled symptoms.20 A key target is to reduce emergency presentations, as they are distressing for patients.21 Statement 14 therefore states that all patients should be offered an initial specialist follow-up appointment to discuss ongoing care within 6 weeks of completing treatment and should be offered regular appointments thereafter.8 The latter could be part of an integrated care model.


Potential barriers to implementation

Medical services have many and varied demands, and a common perception is that resources are too limited to achieve certain ‘aspirational standards’. In cancer services, the waiting-time targets have been very helpful in directing attention to this most distressing disease.13 However, focusing on targets increases the danger that less attention is given to ensuring that the best treatment is offered. The new quality standard from NICE on lung cancer should encourage clinical teams to adhere to targets and achieve better outcomes.8

A dedicated and enthusiastic team is essential, especially as clinicians often feel obliged to work beyond their contractual obligations in order to help their patients. The capacity to provide certain diagnostic tests—for example, endobronchial ultrasound—needs to be increased, which is, again, dependent on enthusiastic clinicians. Access to lung-cancer clinicians who are willing to deliver state-of-the-art therapy to borderline patients can be limited, and it is important that all cancer networks have sufficient clinicians.

Although radiotherapy capacity is being increased in the UK, this will remain a limitation in the near future. The need to address the quality standard and the Commissioning Outcomes Framework will undoubtedly help. In these times of austerity in the NHS, lung-cancer nurse-specialist posts are often under threat. Such posts are very important in delivering excellent treatment to patients with lung cancer and ensuring that the levels of care set out in this quality standard are met.

Awareness and early diagnosis present a significant challenge, although much work is planned through NAEDI. Lung cancer is more common in groups of people who are known to be hard to reach, and getting the message that early diagnosis is crucial across to these people is very important. The new quality standard on lung cancer will be a useful aid to healthcare professionals and patients alike, and its implementation will lead to improved outcomes across lung cancer services in NHS.

Conclusion

The NICE quality standard for lung cancer, in just 15 statements, sets the level of care that lung-cancer services should achieve if we are to continue the trend towards better survival and more active treatment in lung cancer.8 A modern approach to encouraging early presentation, accurate assessment, and appropriate treatment can further improve survival and mortality. In secondary care, the challenge is to ensure that the high standards of care found in some UK centres and abroad are applied universally. Considerable progress is being made, with greater access to diagnostic and staging investigations, increased numbers of thoracic surgeons, and more modern radiotherapy equipment. For primary and integrated care, the challenges are to promote public awareness and to respond promptly to warning symptoms, particularly persistent cough, and extending this to include more patients, which will result in greater numbers of referrals for imaging or assessment at rapid-access clinics.


  • Commissioners need to ensure that their local cancer network is working towards achieving the quality standard for lung cancer and that they have robust CCG representation
  • Performance against NICE quality standards will form part of the Commissioning Outcome Framework
  • Early diagnosis and prevention (smoking cessation) could be addressed through multi-agency interventions and could be coordinated through Health and Wellbeing Boards
  • Primary care services should be aware of and participate in campaigns to stimulate earlier presentation and referral
  • A simple localised version of the NICE referral pathway should be produced and shared with local services.
  1. Cancer Research UK website. CancerStats—cancer statistics for the UK. info.cancerresearchuk.org/cancerstats/mortality/ (accessed on 17 July 2012).
  2. Coleman P, Forman D, Bryant H et al. Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK (the International Benchmarking Partnership): an analysis of population-based cancer registry data. Lancet 2011; 377 (9760): 127–138.
  3. Holmberg L, Sandin F, Bray F et al. National comparisons of lung cancer survival in England, Norway and Sweden 2001–2004: differences occur early in follow-up. Thorax 2010; 65 (5): 436–441.
  4. National Cancer Intelligence Network website. Routes to diagnosis—NCIN data briefing.
    www.ncin.org.uk/publications/data_briefings/routes_to_diagnosis.aspx (accessed 17 July 2012).
  5. The NHS Information Centre. National lung cancer audit 2010. Leeds: NHS IC, 2011. Available at: www.ic.nhs.uk/webfiles/Services/NCASP/audits%20and%20reports/NHSIC_National_Lung_Cancer_Audit_2010_V1.0.pdf
  6. Rich A, Tata L, Free C et al. Inequalities in outcomes for non-small cell lung cancer: the influence of clinical characteristics and features of the local lung cancer service. Thorax 2011; 66 (12): 1078–1084.
  7. Rich A, Tata L, Free C et al. How do patient and hospital features influence outcomes in small-cell lung cancer in England? Br J Cancer 2011; 105 (6): 746–752.
  8. National Institute for Health and Care Excellence website. NICE quality standard for lung cancer for adults. www.nice.org.uk/guidance/qualitystandards/lungcancer/home.jsp (accessed 17 July 2012).
  9. National Institute for Health and Care Excellence. The diagnosis and treatment of lung cancer (update). Clinical Guideline 121. London: NICE, 2011. Available at: www.nice.org.uk/guidance/CG121 nhs_accreditation
  10. National Institute for Health and Care Excellence website. NICE quality standard for patient experience in adult NHS services. Available at: www.nice.org.uk/guidance/qualitystandards/patientexperience/home.jsp (accessed 17 July 2012).
  11. National Institute for Health and Care Excellence website. NICE quality standard for end of life care. Available at: www.nice.org.uk/guidance/qualitystandards/endoflifecare/home.jsp (accessed 17 July 2012).
  12. National Institute for Health and Care Excellence. Referral guidelines for suspected cancer. Clinical Guideline 27. London: NICE, 2005. Available at: www.nice.org.uk/CG27
  13. Lewis N, Le Jeune I, Baldwin D. Under utilisation of the 2-week wait initiative for lung cancer by primary care and its effect on the urgent referral pathway. Br J Cancer 2005; 93 (8): 905–908.
  14. National Awareness and Early Diagnosis Initiative for England (NAEDI) website.
    info.cancerresearchuk.org/spotcancerearly/naedi (accessed 17 July 2012).
  15. National Cancer Action Team website. Diagnosing cancer earlier. www.ncat.nhs.uk/our-work/diagnosing-cancer-earlier/public-awareness#tab-overview (accessed 8 August 2012).
  16. National Institute for Health and Care Excellence. Erlotinib for the treatment of non-small-cell lung cancer. Technology Appraisal 162. London: NICE, 2008. Available at: www.nice.org.uk/TA162 nhs_accreditation
  17. National Institute for Health and Care Excellence. Pemetrexed for the first-line treatment of non-small-cell lung cancer. Technology Appraisal 181. London: NICE, 2009. Available at: www.nice.org.uk/TA181 nhs_accreditation
  18. National Institute for Health and Care Excellence. Gefitinib for the first-line treatment of locally advanced or metastatic non-small-cell lung cancer. Technology Appraisal 192. London: NICE, 2010. www.nice.org.uk/TA192 nhs_accreditation
  19. National Institute for Health and Care Excellence. Topotecan for the treatment of relapsed small-cell lung cancer. Technology Appraisal 184. London: NICE, 2009. Available at: www.nice.org.uk/TA184 nhs_accreditation
  20. Younes R, Gross, J, Deheinzelin, D. Follow-up in lung cancer: how often and for what purpose? Chest 1999, 115: 1494–1499.
  21. Department of Health. Improving outcomes: a strategy for cancer. London: DH, 2011. Available at: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123394.pdf G