Chest
Volume 143, Issue 5, Supplement, May 2013, Pages 7S-37S
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Executive Summary: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

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Methodology for Development of Guidelines for Lung Cancer

There have been major advances in the clinical science of lung cancer. There have also been major advances in methodologic science. The ACCP has been at the forefront of these advances and is committed to continuing to evolve the process of literature review, data extraction, and guideline development. With the advancement of methodologic techniques, content experts and methodologists must work hand in hand to bring the best each has to offer to bear on the process. Because resources are not

Epidemiology of Lung Cancer

The epidemiology of lung cancer is an active field. Researchers in the area of molecular epidemiology are making advances in the identification of biomarkers of risk and for early detection, although these are not yet mature enough for clinical application.

Cigarette smoking remains the predominant risk factor for lung cancer. A dramatic increase in deaths from lung cancer is anticipated in the developing world, given the current high rate of smoking in these regions. This will have significant

Molecular Biology of Lung Cancer

Much attention has been directed toward identification of particular genetic mutations that can be treated with targeted therapy, resulting in a major palliative benefit for these patients with advanced non-small cell lung cancer (NSCLC). We appear to be poised to reap more far-reaching benefits by using the tools of molecular biology to gain insight into the development of various lung cancers, determinants of progression, and the identification of specific biomarkers. This has the potential

Chemoprevention of Lung Cancer

The idea of an agent that could prevent the progression to invasive cancer in individuals at high risk is appealing. Unfortunately, despite preliminary data suggesting a possible chemopreventative effect, all of the agents that have been tested in large randomized controlled trials (RCTs) have shown no benefit; some have even turned out to be harmful.

Despite this disappointment, the increasing insight into the fundamental biology of the development of lung cancer provides new opportunities to

Treatment of Tobacco Use in Lung Cancer

Smoking is a difficult addiction to overcome. However, significant advances have been made in understanding some of the reasons for the seemingly paradoxical situation of patients who have developed lung cancer yet have difficulty giving up smoking. More importantly, not only are there several therapeutic interventions that can assist those trying to stop smoking but there is a fairly sophisticated understanding of which intervention or combination of interventions has the best chance of

Screening for Lung Cancer

Major progress has been made in defining the role of screening for lung cancer. The results of a major RCT evaluating chest radiographs is consistent with earlier RCTs, showing that this is not a useful screening test. There are several RCTs evaluating the role of LDCT scanning. The largest of these is the National Lung Cancer Screening Trial (NLST), which has reported a reduction in lung cancer deaths among screened individuals. This involved patients with a significant risk of lung cancer due

Evaluation of Individuals With Pulmonary Nodules: When Is It Lung Cancer?

The management of a solitary pulmonary nodule has been addressed extensively, yet most pulmonologists and thoracic surgeons use an approach that is not closely grounded in solid evidence. The management of these patients is somewhat complex and is influenced by many considerations (eg, the risk of malignancy based on the patient's history and features of the lesion), patient characteristics (eg, lung function), patient values and preferences, and the reliability of various tests.

This article

Clinical and Organizational Factors in the Initial Evaluation of Patients With Lung Cancer

Patients with lung cancer may present with no symptoms, symptoms related to the primary tumor, or symptoms related to distant metastases. A number of paraneoplastic effects are also seen. The evaluation starts with a careful history and physical examination. The tasks of the initial evaluation, namely to establish a diagnosis and clinical stage and develop a treatment plan, proceed in an overlapping, not sequential manner. Involving a multidisciplinary team early during these processes can make

Establishing the Diagnosis of Lung Cancer

In most patients, the diagnosis of lung cancer is best established in a way that simultaneously confirms the stage of disease. If there is a pleural effusion, this represents an obvious target; however, there is a substantial false-negative rate to thoracentesis and cytology. Biopsy of distant sites or mediastinal nodes may be indicated but is covered elsewhere.

Many techniques are available to diagnose the primary tumor. This article extensively reviews the data for these, parsed out for

Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery

Surgery remains the mainstay of treatment of early-stage lung cancer, and assessment of a patient's ability to tolerate a resection is important. Patients should undergo a simple cardiac risk assessment, with further investigation (ie, cardiopulmonary exercise testing) if this suggests potential complications. Assessment of pulmonary reserve should include both spirometry and diffusion capacity, calculated as a predicted postoperative value (taking into account the intended resection) and

The Stage Classification of Lung Cancer

Having a consistent nomenclature is crucial to being able to communicate and compare data from different studies and centers. The official worldwide stage classification system (seventh edition) is based on an unprecedented initiative of the International Association for the Study of Lung Cancer involving a database of > 100,000 patients diagnosed between 1990 and 2000. This system is the basis for the nomenclature used in the third edition of the ACCP Lung Cancer Guidelines. This article

Methods of Staging for Non-small Cell Lung Cancer

Accurately defining the anatomic extent of disease is critical to selecting the appropriate therapy for patients with lung cancer. Many studies have provided additional data regarding how best to achieve this. PET imaging has assumed a prominent role, but it is important to confirm positive PET findings with a biopsy in most situations. The clinical setting and the extent of additional staging tests influences the impact of PET—the. benefit being most marked in patients at greater risk of

Diagnostic Surgical Pathology in Lung Cancer

Details of the pathologic assessment of lung cancer have become more important. Definition of the histologic subtype of NSCLC is crucial in selection of chemotherapy regimens. Further subtyping of adenocarcinoma may be important in determining biologic behavior and the extent of local therapy. This article provides a framework for the pathologist in assessment of lung cancers with immunohistochemical and genetic tests. Reporting is ideally done in a standardized form, but communication with

Diagnosis and Treatment of Bronchial Intraepithelial Neoplasia and Early Lung Cancer of the Central Airways

A small number of patients present with a superficial neoplastic lesion of the central airways (ie, high-grade dysplasia, carcinoma in situ, and small foci of invasive cancer). Autofluorescence bronchoscopy is more sensitive at detecting such lesions. A number of endobronchial treatments have been tried, most prominently photodynamic therapy. However, the natural history of these precancerous lesions is poorly defined, and many appear to regress over time. Therefore the impact of detection and

Treatment of Stage I and II Non-small Cell Lung Cancer

Although the mainstay of treatment of stage I or II NSCLC remains surgical resection, significant advances in understanding nuances have occurred. An extensive body of data demonstrates better outcomes when resection is performed by surgeons with specialty training, or when done in a higher-volume center or in a teaching facility. However, the understanding is lacking of exactly what processes lead to these outcomes, making it difficult to disseminate successful practices to improve outcomes

Treatment of Stage III Non-small Cell Lung Cancer

The management of stage III NSCLC is among the most confusing and controversial areas, despite the many papers published on the subject. In part, this stems from the fact that stage III involves a broad spectrum of disease burden, from patients with extensive mediastinal infiltration, others with discrete mediastinal node involvement, and those only found to have a small focus of nodal involvement after resection despite negative preoperative invasive mediastinal staging. For some questions

Treatment of Stage IV NSCLC

Significant advances continue to be made in the treatment of stage IV NSCLC; although cure is not possible, significant palliation in terms of improved quality of life (QOL) and duration of survival can be accomplished. Significant clarity has been achieved in terms of which agents to use in very specific situations. The choice of chemotherapy is directed to a large extent by the histologic type of NSCLC, making it all the more important to have adequate material for a detailed diagnosis.

Special Treatment Issues in NSCLC

There are several relatively unusual presentations of NSCLC for which the anatomic and biologic issues dictate a different approach. This includes patients with Pancoast tumors, T4N0,1M0 central tumors, chest wall involvement, additional pulmonary tumor nodules, synchronous and metachronous second primary lung cancers, multifocal lung cancer, and solitary metastases.

Patients with Pancoast tumors appear to have the best outcomes after preoperative chemoradiotherapy and surgical resection,

Treatment of Small Cell Lung Cancer

The stage classification of SCLC should now include TNM staging. Definition of the stage is improved through the use of PET imaging, which results in both upstaging and downstaging of some patients. It is well established that for limited-stage (LS) SCLC concurrent chemoradiotherapy is best, with the radiation being included early in the treatment course. A platinum agent combined with a topoisomerase inhibitor is standard, although irinotecan can also be used in patients with extensive-stage

Complementary Therapies and Integrative Medicine in Lung Cancer

Complementary therapies are rational, evidence-based techniques that alleviate physical and emotional symptoms, improve QOL, and may improve adherence to oncology treatment regimens. Integrative medicine describes the adjunctive role played by complementary therapies as part of multidisciplinary mainstream cancer care. This is an area that most lung cancer clinicians know relatively little about. The degree to which these techniques have been subjected to careful scientific evaluation surprises

Follow-up and Surveillance of the Patient With Lung Cancer After Curative-Intent Therapy

Variation exists in the type and schedule of follow-up of patients who have undergone curative-intent therapy for lung cancer (see Fig 1 in Colt et al5 in LC III). This article includes a very extensive literature search and summary of the data to define this. It is interesting that there are more data available for relatively infrequent situations and treatments (eg, endobronchial therapies, carcinoid tumors) than for the much larger cohort of patients treated with surgery, chemotherapy, or

Symptom Management in Patients With Lung Cancer

Many patients with lung cancer suffer from symptoms such as pain, dyspnea, cough, neurologic symptoms, fatigue, depression, anxiety, and other psychologic difficulties. This is especially true of those with advanced disease, and a specific focus on palliation of symptoms is tremendously important for these patients. Many tools have been developed that can facilitate and streamline the process of providing palliative care.

The symptom management article provides an evidence-based structure for

Palliative and End-of-Life Care in Lung Cancer

Although many effective treatments are available even for patients with incurable lung cancer, at some point the focus becomes how best to manage end-of-life issues. It is best when this issue is incorporated from the outset into the management of patients with incurable disease rather than avoided until death is imminent. Furthermore, palliative care should be integrated with active cancer treatment in these patients. Although many clinicians consider end-of-life conversations difficult,

Acknowledgments

Author contributions: Dr Detterbeck had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Detterbeck: contributed to writing and revising this article.

Dr Lewis: contributed to reviewing drafts, providing comments, and approving the final article.

Ms Diekemper: contributed to reviewing drafts, providing comments, and approving the final article.

Dr Addrizio-Harris: contributed to reviewing drafts, providing

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Funding/Sponsors: The development of this guideline was supported primarily by the American College of Chest Physicians. The lung cancer guidelines conference was supported in part by a grant from the Lung Cancer Research Foundation. The publication and dissemination of the guidelines was supported in part by a 2009 independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.

COI grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.

Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://dx.doi.org/10.1378/chest.1435S1.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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