Clinical practice guidelines for the treatment of lung cancer

For inoperable Stage 3 lung cancer, combined modality chemoradiotherapy is clearly an optimal choice. My issue is getting radiotherapists to agree to treat large lung volumes for fear of radiaton pneumonitis. If this is a legitimate concern and if combined modality is the optimum way forward for these patients, then perhaps the radiation therapists need to clarify exactly what they are willing to radiate and conisder specialized (potentially more expensive) approaches such as IMRT or possibly sequential chemo followed by chemoradiotherapy.Thes issues are not clarified by the guidelines.

First up, this is an outstanding piece of work which the authors and organizing team should be very proud of. The sections are well set out and easily navigated. The quality of the opinions are excellent and well referenced. I was particularly pleased that the links are included back to PubMed and many of the articles can be retrieved direct on the fly. Discussions of evidence are robust and well informed. The ability to submit evidence is welcome (but may represent a rod for your own backs!).

Where this style excels is for reference before (or possibly even during) an MDM discussion where a particular facet of management is being contemplated. I took it for a test drive whilst filling in my MDM pro forma today and found several (minor) areas where our current practice was not well supported by the evidence. Given that this is a key role for the software it follows that fast navigation will be absolutely critical. Hence I will comment on this first.

The search box doesn't like typos (unsurprising) but if I search for cerebral metastases I get nothing, whilst brain metastases gets many hits but brain mets gets none. Some way of tagging the sections might help the searcher?

If I access via the Lung Cancer page and search for PET/CT I get a number of results for endometrial cancer. Can this be altered so whilst in the lung cancer guidelines search results only pertain to lung cancer? After all, in a lung cancer MDM if I need to look something up I don't want to wade through non-lung results. Conversely if I want to look up a non-lung topic I would specify the organ in that search. Maybe a "Search in Lung" as opposed to "Search all site", but better to have one box with smarter filters.

Another possibility would be some kind of grid for NSCLC where tags could be selected e.g. "stage IIa" "inoperable" and "radiotherapy" could be selected and the relevant article appears. It would have to be neat & tidy though, else would be a distraction from the main body of work. Alternatively, Advice for NSCLC and SCLC could be presented on a different coloured background to allow easy differentiation.

SCLC is still referred to as limited or extensive against 7th TNM staging, which will change with time as the evidence is reappraised I guess. With regards to scope, I assume the SCLC / NSCLC dichotomy has been chosen for pragmatic reasons, as I could find no mention of invasive adenocarcinoma of lepidic type (bronchoalveolar cell carcinoma), or the management of paraneoplastic manifestations, for instance. Not that evidence in these circumstances is thick on the ground.

There are a handful of minor typos and grammatical errors. Should these be commented on in individual sections and if so will the comments remain there to reveal my pedantry forever, or are comments relayed to the author for amendment as needed and then deleted or shunted off into storage? Minor typos etc tend to get kept on wikis but are mainly irrelevant.

Are sections that are recently updated marked out as such? This would be one way of keeping up to date with new evidence. EDIT: I see that can be done after registration, thanks.

Very minor one - when browsing in Safari 5.1.7 on OSX 10.7.3 pressing enter after typing a search query doesn't work, search has to be manually clicked. Works fine on Chrome 20, Firefox 12.0 & Opera 12 though (multiple hits of enter needed). I like the boolean search. I haven't looked at the site in IE, but the formatting is excellent on OSX browsers.

Clearly the guidance relates to treatment only at present - are there plans to extend to investigation etc?

Overall, I think this a fine body of work that should form a standard to which others aspire. Congratulations to all involved. I gather this is a world first, and you are certainly leading the way. Thanks for all your hard work.

Multidisciplinary lung cancer meetings for patients with lung cancer

The management of patients with cancer is complex. Formal multidisciplinary team (MDT) meetings have been widely promoted to improve coordination, communication and decision making in cancer management.1 The use of MDT may be particularly important for patients with thoracic malignancies.2,3 Research demonstrating the effectiveness of MDT in improving cancer outcomes is relatively scarce.1,4

One study from Scotland, compared the treatment and survival of patients with inoperable non-small cell lung cancer (NSCLC) at a single institution treated before and after the introduction of a MDT. It found an increase in the use of chemotherapy from 7% to 23% and an association with an increase in median survival from 3.2 to 6.6 months.5 However, as the two periods studied (1997 and 2001) were separated by 4 years, the observed differences might have been due to factors other than MDT meetings alone.

An Australian study subsequently looked at patients with inoperable NSCLC diagnosed and managed at a single institution over a one-year period. Those patients whose case had been discussed at a multidisciplinary meeting had better survival than those whose case was not discussed (mean survival; 280 days vs. 205 days, p = 0.048).6 Another Australian study, looking at al patients with a new lung cancer diagnosis (all stages of both SCLC and NSCLC, not necessarily pathologically proven). They found patients presented at MDT meetings were more likely to receive radiotherapy (66% vs. 33%, p < .001); chemotherapy (46% vs. 29%; p < .001); and referral to palliative care (66% vs. 53%; p < .001).7 In that study MDT meeting discussion did not influence survival.

Experts attending a national Australian lung cancer meeting were surveyed regarding multidisciplinary lung cancer meetings.8 The vast majority of respondents recommended the attendance of each of Respiratory physicians, Cardiothoracic surgeons, Radiation oncologists, Medical oncologists, Nuclear medicine physicians, Radiologists, Pathologists, Palliative care physicians and Nurse coordinators. In most cases meetings met clinicians’ needs. However there were concerns about adequate attendance and resources (including e.g. adequate time, computerised databases).

Evidence Summary

-Patients with lung cancer benefit from multidisciplinary team discussion -Multidisciplinary lung cancer meetings need to be adequately attended and resourced

Recommendations

- Patients with lung cancer should routinely be discussed at multidisciplinary lung cancer meetings - Multidisciplinary lung cancer meetings should be adequately attended and resourced

References

1. Fleissig A, Jenkins V, Catt S, Fallowfield L. Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncol 2006; 7: 935–43. 2. Alberts WM, Bepler G, Hazelton T, Ruckdeschel JC, Williams JH. Lung cancer. Practice organization. Chest 2003; 123 (1 Suppl): 332S–337S. 3. Coory M, Gkolia P, Yang IA, Bowman RV, Fong KM. Systematic review of multidisciplinary teams in the management of lung cancer. Lung Cancer 2008; 60: 14–21. 4. Wright F, De Vito C, Langer B, Hunter A. Multidisciplinary cancer conferences: a systematic review and development of practice standards. Eur J Cancer 2007; 43: 1002–10. 5. Forrest LM, McMillan DC, McArdle CS, Dunlop DJ. An evaluation of the impact of a multidisciplinary team, in a single centre, on treatment and survival in patients with inoperable non-small-cell lung cancer. Br J Cancer 2005; 93: 977–8. 6. Bydder S, Nowak A, Marion K, Phillips M, Atun R. The impact of case discussion at a multidisciplinary team meeting on the treatment and survival of patients with inoperable non-small cell lung cancer. Intern Med J. 2009; 39: 838-41. 7. Boxer MM, Vinod SK, Shafiq J, Duggan KJ. Do multidisciplinary team meetings make a difference in the management of lung cancer? Cancer. 2011; 117:5112-20. 8. Bydder S, Hasani A, Broderick C, Semmens J. Lung cancer multidisciplinary team meetings: A survey of participants at a national conference. J Med Imaging Radiat Oncol. 2010; 54: 146-51.

We propose the final document should include a Preamble to incorporate new developments in the staging process, the new sub-classification of lung cancer by histopathology and molecular pathology, and the implications for treatment and tissue acquisition. The Preamble could also address the criteria for ‘operability’ where reference is made. This might be on the basis of other medical considerations.