Summary of recommendations

Summary of recommendations

This page provides a summary of the recommendations in the published guidelines.

This guideline includes evidence-based recommendations (EBR), consensus-based recommendations (CBR) and practice points (PP) as defined in the table below. Recommendations and practice points were developed by working party members and sub-committee members.

Each EBR was assigned a grade by the expert working group, taking into account the volume, consistency, generalisability, applicability and clinical impact of the body of evidence according to NHMRC Level and Grades for Recommendations for Guidelines Developers.

NHMRC approved recommendation types and definitions

Type of recommendation	Definition
Evidence-based recommendation	A recommendation formulated after a systematic review of the evidence, indicating supporting references
Consensus-based recommendation	A recommendation formulated in the absence of quality evidence, after a systematic review of the evidence was conducted and failed to identify admissible evidence on the clinical question
Practice point	A recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process

Source: National Health and Medical Research Council. Procedures and requirements for meeting the NHMRC standard for clinical practice guidelines. Melbourne: National Health and Medical Research Council, 2011

You may also like to refer to the Guideline Development Handbook for details on the levels of evidence and recommendation grades.

Recommendations

Screening and early detection

In people at risk of lung cancer, does population based screening with chest radiography reduce mortality?

Evidence-based recommendation	Grade
Chest radiography is not recommended for lung cancer screening in asymptomatic individuals.	A

• Clinical question:In people at risk of lung cancer, does population based screening with chest radiography reduce mortality?#Recommendation_1
• Chest radiography is not recommended for lung cancer screening in asymptomatic individuals.
• Recommendation

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In people at risk of lung cancer, does population based CT screening reduce mortality?

Evidence-based recommendation

Grade

There is insufficient evidence to recommend population-based CT Screening.* * Despite the existing evidence from North America that computed tomography (CT) screening can reduce lung cancer specific and all-cause mortality in some people at high risk for lung cancer, current uncertainties including the generalisability of this international trial result to the Australian setting, the lack of local cost effectiveness evidence, and concerns as how best to implement a safe and effective screening program in Australia, mean that the available evidence is insufficient to recommend population based CT screening in Australia at the current time.

B

• Clinical question:In people at risk of lung cancer, does population based CT screening reduce mortality?#Recommendation_1
• There is insufficient evidence to recommend population-based CT Screening.^*

^* Despite the existing evidence from North America that computed tomography (CT) screening can reduce lung cancer specific and all-cause mortality in some people at high risk for lung cancer, current uncertainties including the generalisability of this international trial result to the Australian setting, the lack of local cost effectiveness evidence, and concerns as how best to implement a safe and effective screening program in Australia, mean that the available evidence is insufficient to recommend population based CT screening in Australia at the current time.

• Recommendation

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Which population group would potentially most benefit from CT screening for lung cancer?

Evidence-based recommendation

Grade

CT scans for the early detection of lung cancer in asymptomatic individuals should only be considered in those at high risk of lung cancer and who meet the following minimum criteria: aged 55-74 with heavy smoking histories (at least 30 pack years, current or former smokers who have quit within the prior 15 years).* *See the section on population-based CT screening for more information.Available evidence is insufficient to recommend populated based CT screening.

C

• Clinical question:Which population group would most benefit from CT screening for lung cancer?#Recommendation_1
• CT scans for the early detection of lung cancer in asymptomatic individuals should only be considered in those at high risk of lung cancer and who meet the following minimum criteria: aged 55-74 with heavy smoking histories (at least 30 pack years, current or former smokers who have quit within the prior 15 years).*

*See the section on population-based CT screening for more information.Available evidence is insufficient to recommend populated based CT screening.

• Recommendation

Practice point
Current evidence does not support population-based screening with CT scanning. For the asymptomatic individual at high risk for lung cancer who is considering a CT scan to detect early lung cancer, it is recommended that they discuss any potential benefits against the potential harms of a low dose CT scan with their GP.

• Clinical question:Which population group would most benefit from CT screening for lung cancer?#Practice_point_1
• Current evidence does not support population-based screening with CT scanning.

For the asymptomatic individual at high risk for lung cancer who is considering a CT scan to detect early lung cancer, it is recommended that they discuss any potential benefits against the potential harms of a low dose CT scan with their GP.

• Good practice point

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Diagnosis and staging

When is IHC required for subtyping of NSCLC and what is the optimal IHC panel?

Evidence-based recommendation	Grade
A small panel of IHC markers should be used to subtype morphologically undifferentiated NSCLC in small biopsy and cytology samples, with 2 markers usually sufficient (1 adenocarcinoma marker and 1 squamous marker).	C

• Clinical question:When is IHC required for subtyping of NSCLC and what is the optimal IHC panel?#Recommendation_1
• A small panel of IHC markers should be used to subtype morphologically undifferentiated NSCLC in small biopsy and cytology samples, with 2 markers usually sufficient (1 adenocarcinoma marker and 1 squamous marker).
• Recommendation

Practice point

IHC to assist in subtyping NSCLC is only required when there is no morphological evidence of glandular or squamous differentiation.The optimal panel of IHC markers is not clear from the literature with many studies using a different range of markers (eg TTF-1, Napsin A, CK5, CK5/6, p40, p63, CK7, surfactant protein A, as well as histochemical markers for mucin such as PAS.) The WHO Classification of Tumours of the Lung (Travis WD et al 2015) recommends using only one squamous marker (ie p40, p63 or CK5/6) and one adenocarcinoma marker (TTF-1 or a histochemical stain for mucin) so as to preserve tissue for molecular testing in the setting of a small biopsy showing a non-small cell carcinoma lacking definite squamous or glandular morphology.

• Clinical question:When is IHC required for subtyping of NSCLC and what is the optimal IHC panel?#Practice_point_1
• IHC to assist in subtyping NSCLC is only required when there is no morphological evidence of glandular or squamous differentiation.The optimal panel of IHC markers is not clear from the literature with many studies using a different range of markers (eg TTF-1, Napsin A, CK5, CK5/6, p40, p63, CK7, surfactant protein A, as well as histochemical markers for mucin such as PAS.) The WHO Classification of Tumours of the Lung (Travis WD et al 2015) recommends using only one squamous marker (ie p40, p63 or CK5/6) and one adenocarcinoma marker (TTF-1 or a histochemical stain for mucin) so as to preserve tissue for molecular testing in the setting of a small biopsy showing a non-small cell carcinoma lacking definite squamous or glandular morphology.
• Good practice point

Practice point
It is advisable to limit the number of IHC markers used to 2 so as to preserve tissue for molecular testing if required (1 adenocarcinoma marker such as TTF1, and 1 squamous marker such as p40).

• Clinical question:When is IHC required for subtyping of NSCLC and what is the optimal IHC panel?#Practice_point_2
• It is advisable to limit the number of IHC markers used to 2 so as to preserve tissue for molecular testing if required (1 adenocarcinoma marker such as TTF1, and 1 squamous marker such as p40).
• Good practice point

Practice point

In some instances, IHC may also be needed to help determine if the tumour is of lung origin or a metastasis. Clinicopathological correlation and multidisciplinary team meeting discussion can often assist in excluding the possibility of a metastasis to the lung in the setting of a solitary lung lesion, and can help avoid unnecessary use of IHC markers and thereby preserve tissue for molecular testing. IHC markers are not useful in distinguishing primary from metastatic disease in the case of a squamous cell carcinoma in the lung.

• Clinical question:When is IHC required for subtyping of NSCLC and what is the optimal IHC panel?#Practice_point_3
• In some instances, IHC may also be needed to help determine if the tumour is of lung origin or a metastasis. Clinicopathological correlation and multidisciplinary team meeting discussion can often assist in excluding the possibility of a metastasis to the lung in the setting of a solitary lung lesion, and can help avoid unnecessary use of IHC markers and thereby preserve tissue for molecular testing. IHC markers are not useful in distinguishing primary from metastatic disease in the case of a squamous cell carcinoma in the lung.
• Good practice point

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What specimen types are suitable for mutation testing in NSCLC patients?

Evidence-based recommendation	Grade
Any tumour sample can be used for mutation testing (sample from primary or metastatic site; histology or cytology sample).	C

• Clinical question:What specimen types are suitable for mutation testing in NSCLC patients?#Recommendation_1
• Any tumour sample can be used for mutation testing (sample from primary or metastatic site; histology or cytology sample).
• Recommendation

Practice point
It is advisable to use the optimal specimen available from each patient for mutation testing (if more than one specimen is available). This would be the specimen with the highest content and proportion of tumour cells and could be a histology specimen such as a core biopsy or a cytology specimen. This should be determined on a case by case basis by a pathologist.

• Clinical question:What specimen types are suitable for mutation testing in NSCLC patients?#Practice_point_1
• It is advisable to use the optimal specimen available from each patient for mutation testing (if more than one specimen is available). This would be the specimen with the highest content and proportion of tumour cells and could be a histology specimen such as a core biopsy or a cytology specimen. This should be determined on a case by case basis by a pathologist.
• Good practice point

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In people undergoing lung cancer evaluation, does concurrent diagnosis and staging provide greater benefit for patient outcomes compared to sequential testing for diagnosis followed by staging?

Consensus-based recommendation

In suspected lung cancer, where possible, clinicians should select a first diagnostic procedure which can provide diagnosis and staging concurrently. However, other considerations include the safety of each test for an individual patient, and the need to obtain an adequate sample for required pathological testing. CT PET scanning should be obtained prior to endobronchial/endoscopic ultrasound in potentially curative cases.

• Clinical question:In people undergoing lung cancer evaluation, does concurrent diagnosis and staging provide greater benefit for patient outcomes compared to sequential testing for diagnosis followed by staging?#Practice_point_1
• In suspected lung cancer, where possible, clinicians should select a first diagnostic procedure which can provide diagnosis and staging concurrently. However, other considerations include the safety of each test for an individual patient, and the need to obtain an adequate sample for required pathological testing. CT PET scanning should be obtained prior to endobronchial/endoscopic ultrasound in potentially curative cases.
• Consensus based recommendation

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For patients undergoing workup for known or suspected lung cancer, what is the optimal timing of PET/CT? Before or after tissue biopsy confirmation?

Practice point

In the absence of evidence to guide optimal timing of PET/CT in the workup of known or suspected lung cancer (NSCLC) it is advisable to: 1. Offer PET/CT to all patients who are considered for curative therapy. 2. Consider the use of PET/CT prior to biopsy in order to guide biopsy as well as to stage disease. 3. Consider the use of PET/CT at any stage in order to evaluate the extent of metastatic disease. 4. Consider the use of "flat-top" table position for PET/CT as this is the radiotherapy planning position; this may avoid the need for a second scan to plan for radiotherapy.

• Clinical question:Lung cancer staging optimal timing PET-CT and biopsy#Practice_point_1
• In the absence of evidence to guide optimal timing of PET/CT in the workup of known or suspected lung cancer (NSCLC) it is advisable to:

1. Offer PET/CT to all patients who are considered for curative therapy.
2. Consider the use of PET/CT prior to biopsy in order to guide biopsy as well as to stage disease.
3. Consider the use of PET/CT at any stage in order to evaluate the extent of metastatic disease.
4. Consider the use of "flat-top" table position for PET/CT as this is the radiotherapy planning position; this may avoid the need for a second scan to plan for radiotherapy.

• Good practice point

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For patients undergoing workup for known or suspected lung cancer, what is the optimal timing of PET/CT? Before or after tissue biopsy confirmation?

Practice point

In the absence of evidence to guide optimal timing of PET/CT in the workup of known or suspected lung cancer (NSCLC) it is advisable to: 1. Offer PET/CT to all patients who are considered for curative therapy. 2. Consider the use of PET/CT prior to biopsy in order to guide biopsy as well as to stage disease. 3. Consider the use of PET/CT at any stage in order to evaluate the extent of metastatic disease. 4. Consider the use of "flat-top" table position for PET/CT as this is the radiotherapy planning position; this may avoid the need for a second scan to plan for radiotherapy.

• Clinical question:Lung cancer staging optimal timing PET-CT and biopsy#Practice_point_1
• In the absence of evidence to guide optimal timing of PET/CT in the workup of known or suspected lung cancer (NSCLC) it is advisable to:

1. Offer PET/CT to all patients who are considered for curative therapy.
2. Consider the use of PET/CT prior to biopsy in order to guide biopsy as well as to stage disease.
3. Consider the use of PET/CT at any stage in order to evaluate the extent of metastatic disease.
4. Consider the use of "flat-top" table position for PET/CT as this is the radiotherapy planning position; this may avoid the need for a second scan to plan for radiotherapy.

• Good practice point

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Follow-up

Does routine follow-up improve patient outcomes in people who have curative intent treatments for lung cancer?

Evidence-based recommendation	Grade
It is recommended that patients undergoing curative treatment for lung cancer have regular follow up.	D

• Clinical question:Does routine follow-up improve patient outcomes in people who have curative intent treatments for lung cancer?#Recommendation_1
• It is recommended that patients undergoing curative treatment for lung cancer have regular follow up.
• Recommendation

Evidence-based recommendation	Grade
It is recommended that patients undergo follow up after treatment for non-small cell carcinoma.	D

• Clinical question:Does routine follow-up improve patient outcomes in people who have curative intent treatments for lung cancer?#Recommendation_2
• It is recommended that patients undergo follow up after treatment for non-small cell carcinoma.
• Recommendation

Practice point
It is advisable to utilise the many clinical guidelines available for follow up. There are no local Australian guidelines and the clinician may use the NICE guidelines.

• Clinical question:Does routine follow-up improve patient outcomes in people who have curative intent treatments for lung cancer?#Practice_point_1
• It is advisable to utilise the many clinical guidelines available for follow up. There are no local Australian guidelines and the clinician may use the NICE guidelines.
• Good practice point

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What are the optimal follow-up tests for people with lung cancer who have had curative intent treatment?

Evidence-based recommendation	Grade
Low dose CT should be considered as part of the protocol for follow up of lung cancer patients.	C

• Clinical question:What are the optimal follow-up tests for people with lung cancer who have had curative intent treatment?#Recommendation_1
• Low dose CT should be considered as part of the protocol for follow up of lung cancer patients.
• Recommendation

Evidence-based recommendation	Grade
Consideration should be given to including PET-CT in the follow up for detection of recurrences after 6 months.	D

• Clinical question:What are the optimal follow-up tests for people with lung cancer who have had curative intent treatment?#Recommendation_2
• Consideration should be given to including PET-CT in the follow up for detection of recurrences after 6 months.
• Recommendation

Practice point
It is advisable to consider utilising PET-CT for follow up. There is no evidence to suggest a clear survival benefit even though the probability of detecting early recurrence is higher with PET-CT.

• Clinical question:What are the optimal follow-up tests for people with lung cancer who have had curative intent treatment?#Practice_point_1
• It is advisable to consider utilising PET-CT for follow up. There is no evidence to suggest a clear survival benefit even though the probability of detecting early recurrence is higher with PET-CT.
• Good practice point

Practice point
PET-CT is not reimbursed for follow up of lung cancer patients.

• Clinical question:What are the optimal follow-up tests for people with lung cancer who have had curative intent treatment?#Practice_point_2
• PET-CT is not reimbursed for follow up of lung cancer patients.
• Good practice point

Practice point
It is suggested that the use of PET-CT for follow up be initiated following discussion at a lung cancer multidisciplinary meeting (MDT).

• Clinical question:What are the optimal follow-up tests for people with lung cancer who have had curative intent treatment?#Practice_point_3
• It is suggested that the use of PET-CT for follow up be initiated following discussion at a lung cancer multidisciplinary meeting (MDT).
• Good practice point

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What is the optimal model (provider) of care for the follow up of people with lung cancer who have had curative intent treatment?

Evidence-based recommendation	Grade
A multidisciplinary approach to follow up is ideal, involving the treating specialists, family physician and clinical nurse specialists.	C

• Clinical question:What is the optimal model (provider) of care for the follow up of people with lung cancer who have had curative intent treatment?#Recommendation_1
• A multidisciplinary approach to follow up is ideal, involving the treating specialists, family physician and clinical nurse specialists.
• Recommendation

Evidence-based recommendation	Grade
It is recommended that a nurse specialist ideally be involved, as an member of the team, in the follow up team for patients receiving curative intent treatment for lung cancer.	B

• Clinical question:What is the optimal model (provider) of care for the follow up of people with lung cancer who have had curative intent treatment?#Recommendation_2
• It is recommended that a nurse specialist ideally be involved, as an member of the team, in the follow up team for patients receiving curative intent treatment for lung cancer.
• Recommendation

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