Summary of recommendations
Summary of recommendations
For explanation of levels of evidence and grades for recommendations, see Levels of evidence and grades for recommendations below. You may also like to refer to the Appendix - Guideline development process
Non-small cell lung cancer
Stage I operable
Surgery
Does complete mediastinal lymph node dissection improve overall survival compared to mediastinal lymph node staging in stage I NSCLC?
Point(s) |
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Is minimally invasive lobectomy as effective as open lobectomy for treatment of operable stage I NSCLC?
Radiotherapy
What is the role of radiotherapy in the treatment of operable stage I NSCLC?
Point(s) |
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What is the role of radiotherapy after surgery in the treatment of operable stage I NSCLC?
Chemotherapy
What is the role of chemotherapy before surgery in the treatment of operable stage I NSCLC?
What is the role of chemotherapy after surgery in the treatment of operable stage I NSCLC?
Stage I inoperable
Radiotherapy
What is the best practice radiotherapy approach in patients with stage I inoperable NSCLC?
Point(s) |
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What is the role of radiofrequency ablation in stage I inoperable NSCLC?
Chemotherapy
What is the role of chemotherapy when added to radiotherapy in the treatment of inoperable stage I NSCLC?
Point(s) |
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Stage II operable
Surgery
Does complete mediastinal lymph node dissection improve overall survival compared to mediastinal lymph node staging in stage II NSCLC?
Radiotherapy
What is the role of radiotherapy after surgery in the treatment of operable stage II NSCLC?
Recommendation | Grade |
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A |
Chemotherapy
What is the role of chemotherapy before surgery in the treatment of operable stage II NSCLC?
What is the role of chemotherapy after surgery in the treatment of operable stage II NSCLC?
Recommendation | Grade |
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A |
Point(s) |
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Stage II inoperable
Radiotherapy
What is the best practice radiotherapy approach in patients with stage II inoperable NSCLC?
Point(s) |
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Chemotherapy
What is the role of chemotherapy when added to radiotherapy in the treatment of inoperable stage II NSCLC?
Stage III operable
Radiotherapy
What is the role of postoperative radiotherapy (PORT) in resected stage III NSCLC?
Point(s) |
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Surgery
What is the clinical benefit of mediastinal lymph node dissection in stage IIIA operable NSCLC?
What is the clinical benefit of the addition of surgery to definitive chemoradiotherapy in stage IIIA (N2) NSCLC?
Recommendation | Grade |
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B |
Chemotherapy
What is the clinical benefit of adjuvant chemotherapy for patients with stage III operable NSCLC?
Point(s) |
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What is the clinical benefit of neoadjuvant chemotherapy for patients with stage III operable NSCLC?
Point(s) |
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What is the clinical benefit of the addition of neoadjuvant radiotherapy to neoadjuvant chemotherapy in stage IIIA (N2) NSCLC?
Point(s) |
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Stage III inoperable
Radiotherapy
What is the recommended treatment approach for the definitive management of patients with good performance status and inoperable stage III disease?
What is the optimal radiation dose and fractionation schedule for good performance status patients with inoperable stage III NSCLC undergoing curative therapy?
What are the principles of radiation therapy in the definitive management of stage III inoperable NSCLC?
What is the optimal treatment approach for patients with stage III inoperable NSCLC who, because of patient or tumour factors, are not suitable for curative treatment with concurrent chemo-radiotherapy and who do not have a mutation for targeted therapy?
What is the role of prophylactic cranial irradiation (PCI) in patients with stage III NSCLC?
Recommendation | Grade |
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B |
What is the optimal management of Pancoast tumours?
Stage IV operable
Radiotherapy
What is the clinical benefit of adjuvant whole brain radiotherapy following resection or stereotactic radiosurgery to the brain metastasis(es)?
Recommendation | Grade |
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A |
Surgery
What is the clinical benefit of resection of brain metastasis?
Point(s) |
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What is the clinical benefit of resection of primary disease after complete resection of metastatic disease?
Stage IV inoperable
Radiotherapy
What is the clinical benefit of radiotherapy to the brain for patients with inoperable brain metastases from NSCLC?
What is the role of stereotactic radiosurgery in the treatment of brain metastases?
Point(s) |
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What is the clinical benefit of radiotherapy to the bone for metastatic disease from NSCLC?
What is the clinical benefit of radiotherapy in metastatic spinal cord compression?
Chemotherapy
What is the optimal systemic therapy for stage IV inoperable NSCLC?
Small cell lung cancer
Limited stage
Chemotherapy
What is the optimal systemic therapy and duration to be used for the treatment of limited stage small cell lung cancer?
Point(s) |
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What is the optimal concurrent chemotherapy to be used for the treatment of limited stage small cell lung cancer with radiotherapy?
Radiotherapy
Which patients with SCLC benefit from prophylactic cranial irradiation?
What is the optimal dose and fractionation schedule of prophylactic cranial irradiation in patients with limited stage SCLC?
What is the optimal timing of thoracic radiotherapy in patients receiving chemotherapy for limited stage SCLC?
Point(s) |
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What is the optimal dose and fractionation schedule of thoracic radiotherapy in patients with limited stage SCLC?
What is the optimal treatment volume in patients with limited stage SCLC receiving thoracic radiotherapy?
Extensive stage
Chemotherapy
What is the optimal chemotherapy regimen and duration of therapy in extensive stage small cell lung cancer in the first-line setting?
What is the optimal second-line therapy in patients with extensive stage small cell lung cancer?
Radiotherapy
What is the optimal dose and fractionation schedule of prophylactic cranial irradiation in patients with extensive stage SCLC?
Is there a role for thoracic radiotherapy in patients with extensive stage SCLC?
Point(s) |
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![]() Those patients with the heaviest extrathoracic metastatic burden and poor response to chemotherapy may be expected to benefit the least from thoracic radiotherapy. In addition, patients with no residual disease in the thorax after chemotherapy derived no benefit from consolidative thoracic radiotherapy in a post hoc analysis by Slotman et al.
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Palliative care
What is the role of palliative care in symptom management for patients with lung cancer?
Point(s) |
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![]() - The choice of opioids used may consider issues of availability, cost and individual patient factors such as route of administration, metabolism and organ impairment such as renal failure. |
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![]() -Symptomatic treatment with antimuscuranic agents or antibiotics may be helpful by reducing the volume of secretions or mucopurulant sputum. -Where appropriate and accessible, interventions such as brachytherapy may be beneficial for the management of cough in selected patients. (Refer to Brachytherapy section in Radiotherapy Stage IV)
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What is the role of advance care planning and timing of referral for patients with lung cancer?
What is the role of psychological support and interventions in the treatment of lung cancer?
Supportive care
What is the role of case management in the treatment of patients with lung cancer?
What is the role of topical creams, skin moisturisers and maintenance antibiotics in the treatment of rash from anti-EGFR therapy in patients with lung cancer?
Recommendation | Grade |
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C |
Levels of evidence and grades for recommendations
The following table provides a list of the evidence-based recommendations detailed in the content of each topic question. The table below provides details on the highest level of evidence identified to support each recommendation (I-IV). The Summary of Recommendations table includes the grade for each recommendation (A-D). The key references that underpin the recommendation are provided in the last column. Individual levels of evidence can be found in the Evidence Summaries for each recommendation in each question.
Each recommendation 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 supporting each recommendation. When no Level I or II evidence was available and in some areas, in particular where there was insufficient evidence in the literature to make a specific evidence-based recommendation, but also strong and unanimous expert opinion amongst the working group members about both the advisability of making a clinically relevant statement and its content, recommended best practice points were generated. Thus, the practice points relate to the evidence in each question, but are more expert opinion-based than evidence-based. These can be identified throughout the guidelines with the following: Practice point (PP).
Grade of recommendation | Description |
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A | Body of evidence can be trusted to guide practice |
B | Body of evidence can be trusted to guide practice in most situations |
C | Body of evidence provides some support for recommendation(s) but care should be taken in its application |
D | Body of evidence is weak and recommendation must be applied with caution |
PP
(practice point) |
Where no good-quality evidence is available but there is consensus among Guideline committee members, consensus-based guidance points are given, these are called "Practice points" |
Adapted from: National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC; 2009.[1] (https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf)
Level of evidence was assigned according to the following criteria from the NHMRC Evidence Hierarchy[1]:
Level | Intervention | Diagnosis | Prognosis | Aetiology | Screening |
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I | A systematic review of level II studies | A systematic review of level II studies | A systematic review of level II studies | A systematic review of level II studies | A systematic review of level II studies |
II | A randomised controlled trial | A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among consecutive patients with a defined clinical presentation | A prospective cohort study | A prospective cohort study | A randomised controlled trial |
III-1 | A pseudo-randomised controlled trial (i.e. alternate allocation or some other method) | A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among non-consecutive patients with a defined clinical presentation | All or none | All or none | A pseudo-randomised controlled trial (i.e. alternate allocation or some other method) |
III-2 | A comparative study with concurrent controls:
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A comparison with reference standard that does not meet the criteria required for Level II and III-1 evidence | Analysis of prognostic factors amongst untreated control patients in a randomised controlled trial | A retrospective cohort study | A comparative study with concurrent controls:
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III-3 | A comparative study without concurrent controls:
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Diagnostic case-control study | A retrospective cohort study | A case-control study | A comparative study without concurrent controls:
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IV | Case series with either post-test or pre-test/post-test outcomes | Study of diagnostic yield (no reference standard) | Case series, or cohort study of patients at different stages of disease | A cross-sectional study | Case series |
Source: National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC; 2009. (https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf)
References
- ↑ 1.0 1.1 National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for guideline developers. Canberra: National Health and Medical Research Council; 2009 Available from: https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf.