31st December 2024

Management of lung cancer

All patients with lung cancer should be counselled regarding smoking cessation and supported with the prescription of nicotine replacement therapy and referral to community cessation services.

Management of NSCLC

Early NSCLC: Radical lobectomy with lymph node sampling should be considered for all patients with early NSCLC. Lobectomy carries fewer short-term complications and better preserves lung function than a pneumonectomy.

If ineligible for surgery, radical radiotherapy may be considered. This includes stereotactic ablative radiotherapy (SABR), a particularly precise type of radiotherapy appropriate for smaller tumours, which restricts damage to nearby structures.

Eligibility for surgery should be determined through assessment of operative risk. The following factors should be taken into consideration:

• Performance status
• Presence of comorbidities
• Global risk score to estimate risk of operative mortality
• Cardiac investigations – ECG and echocardiography are usually required; exercise stress testing for reversible myocardial ischaemia may be required depending on the presence of cardiac symptoms and risk factors
• Lung function tests – FEV1 and TLCO (transfer factor of the lung for carbon monoxide) should be measured in all patients, and postoperative dyspnoea should be predicted

Following surgery, adjuvant chemotherapy (a cisplatin-based combination regimen) is offered to those with adequate performance status, depending on staging. Neoadjuvant chemotherapy is only available as part of a clinical trial.

Locally advanced NSCLC: Locally advanced disease involving mediastinal lymph nodes is also potentially curable, and surgery with chemoradiotherapy should be considered. If this is not an option, radical radiotherapy is an alternative.

If operable, lobectomy with lymph node dissection should be offered if technically feasible and if the patient is suitably fit (see above for eligibility criteria). Patients may be offered either neoadjuvant or adjuvant chemotherapy.

Patients whose tumours are inoperable should receive concurrent platinum-based chemotherapy and radiotherapy (radical chemoradiotherapy) as a non-surgical treatment pathway, and this may be followed by durvalumab (an anti-PD-L1 [programmed death-ligand 1] immune checkpoint inhibitor) in PD-L1-positive patients. Pneumonitis secondary to radiotherapy ± durvalumab is the main adverse event.

Metastatic NSCLC: This is incurable, and any treatment has palliative intent. Three modalities of treatment exist:

1. Targeted therapy, chosen based on the presence of specific mutations. Examples include:
   • Tyrosine kinase inhibitors (TKI) – may be offered first line in inoperable locally advanced or metastatic NSCLC with proven mutations. Examples include erlotinib, gefitinib and afatinib, all for tumours with epidermal growth factor (EGFR) mutations. An EGFR-TKI can be used alongside chemotherapy if the patient is fit enough to tolerate it.
   • Crizotinib – with a mutation of the anaplastic lymphoma kinase (ALK) gene. This is a second-line option for patients who have had platinum-based chemotherapy.
2. Immune checkpoint inhibitors (immunotherapy) – for those with no targetable mutation, but with proven PD-L1 expression, e.g. pembrolizumab.
3. Chemotherapy – histology-specific chemotherapy, usually including a platinum-based drug, may be given to those fit for treatment who have no targetable mutation and with a contraindication to immunotherapy.

Management of SCLC

Very early SCLC: SCLC is usually advanced at presentation and only a minority of patients with very early disease qualify for surgical resection aimed at cure. As in NSCLC, extensive work-up is required to ensure fitness for surgery (see above for eligibility criteria). In the minority of patients with SCLC who do proceed to surgical resection, nodal dissection should be performed and adjuvant chemotherapy offered.

Locally advanced SCLC: Nodal disease may be treated curatively with radical chemoradiotherapy.

Metastatic SCLC: Chemotherapy is the mainstay. A platinum-based drug (carboplatin/cisplatin) and etoposide are usually first line. Patients may be eligible for combination with immunotherapy. Atezolizumab is a type of immunotherapy (PDL-1 inhibitor) licensed for extensive small cell lung cancer.