This is the current release of the guideline.

This guideline updates a previous version: Beckles MA, Spiro SG, Colice GL, Rudd RM. The physiologic evaluation of patients with lung cancer being considered for resectional surgery. Chest 2003 Jan;123(1 Suppl):105S-14S.

Definitions for the strength of evidence and recommendation grades (1A-2C) follow the recommendations.

1. It is recommended that patients with lung cancer be assessed for curative surgical resection by a multidisciplinary team, which includes a thoracic surgeon specializing in lung cancer, a medical oncologist, a radiation oncologist, and a pulmonologist. Grade of recommendation, 1C
2. It is recommended that patients with lung cancer not be denied lung resection surgery on the grounds of age alone. Grade of recommendation, 1B
3. It is recommended that patients with lung cancer who are being evaluated for surgery and have major factors for increased perioperative cardiovascular risk have a preoperative cardiologic evaluation. Grade of recommendation, 1C
4. In patients being considered for lung cancer resection, spirometry is recommended. If the Forced Expiratory Volume in the first second (FEV₁) is > 80% predicted or > 2 L and there is no evidence of either undue dyspnea on exertion or interstitial lung disease, the patient is suitable for resection including pneumonectomy without a further physiologic evaluation. If the FEV₁ is > 1.5 L and there is no evidence of either undue dyspnea on exertion or interstitial lung disease, the patient is suitable for a lobectomy without further physiologic evaluation. Grade of recommendation, 1C
5. In patients being considered for lung cancer resection, if there is evidence of either undue dyspnea on exertion or interstitial lung disease, even though the FEV₁ might be adequate, measuring carbon monoxide diffusing capacity (DLCO) is recommended. Grade of recommendation, 1C
6. In patients being considered for lung cancer resection, if either the FEV₁ or DLCO are < 80% predicted, it is recommended that postoperative lung function be predicted through additional testing. Grade of recommendation, 1C
7. In patients with lung cancer who are being considered for surgery, either an FEV₁ of < 40%PPO or a DLCO of < 40%PPO indicates an increased risk for perioperative death and cardiopulmonary complications with standard lung resection. It is recommended that these patients undergo exercise testing preoperatively. Grade of recommendation, 1C
8. In patients with lung cancer who are being considered for surgery, either a product of %PPO FEV₁ and % Predicted Postoperative (PPO) DLCO of < 1,650%PPO or an FEV₁ of < 30% PPO indicates an increased risk for perioperative death and cardiopulmonary complications with standard lung resection. It is recommended that these patients should be counseled about nonstandard surgery and nonoperative treatment options for their lung cancer. Grade of recommendation, 1C
9. In patients with lung cancer being considered for surgery, a VO₂max of < 10 mL/kg/min indicates an increased risk for perioperative death and cardiopulmonary complications with standard lung resection. These patients should be counseled about nonstandard surgery and nonoperative treatment options for their lung cancer. Grade of recommendation, 1C
10. Patients with lung cancer being considered for surgery who have a VO₂max of < 15 mL/kg/min and both an FEV₁ and a DLCO of < 40%PPO are at an increased risk for perioperative death and cardiopulmonary complications with standard lung resection. It is recommended that these patients be counseled about nonstandard surgery and nonoperative treatment options for their lung cancer. Grade of recommendation, 1C
11. Patients with lung cancer being considered for surgery who walk < 25 shuttles on two shuttle walks or less than one flight of stairs are at increased risk for perioperative death and cardiopulmonary complications with standard lung resection. These patients should be counseled about nonstandard surgery and nonoperative treatment options for their lung cancer. Grade of recommendation, 1C
12. In patients with lung cancer who are being considered for surgery, a PaCO₂ of > 45 mm Hg is not an independent risk factor for increased perioperative complications. However, it is recommended that these patients undergo further physiologic testing. Grade of recommendation, 1C
13. In patients with lung cancer who are being considered for surgery, an SaO₂ of < 90% indicates an increased risk for perioperative complications with standard lung resection. It is recommended that these patients undergo further physiologic testing. Grade of recommendation, 1C
14. In patients with very poor lung function and a lung cancer in an area of upper lobe emphysema, it is recommended that combined Lung Volume Reduction Surgery (LVRS) and lung cancer resection be considered if both the FEV₁ and the DLCO are > 20% predicted. Grade of recommendation, 1C
15. It is recommended that all patients with lung cancer be counseled regarding smoking cessation. Grade of recommendation, 1C

Definitions:

Quality of Evidence Scale

High - Randomized controlled trials (RCTs) without important limitations or overwhelming evidence from observational studies*

Moderate - RCTs with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies*

Low or very low - Observational studies or case series

*Although the determination of magnitude of the effect based on observational studies is often a matter of judgment, the guideline developers offer the following suggested rule to assist this decision: a large effect would be a relative risk > 2 (risk ratio < 0.5) [which would justify moving from weak to moderate], and a very large effect is a relative risk > 5 (risk ratio < 0.2) [which would justify moving from weak to strong]. There is some theoretical justification in the statistical literature for these thresholds (the magnitude of effect that is unlikely or very unlikely to be due to residual confounding after adjusted analysis). However, once the decision is made, authors should be explicit in justifying their decisions.

Grade of Recommendations Scale

Relationship of Strength of the Supporting Evidence to the Balance of Benefits to Risks and Burdens

An algorithm is available in the original guideline document for "Preoperative physiologic assessment of perioperative risk."

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2003 Jan (revised 2007 Sep)

American College of Chest Physicians - Medical Specialty Society

American College of Chest Physicians

American College of Chest Physicians (ACCP) Expert Panel on Lung Cancer Guidelines

Primary Authors: Gene L. Colice, MD, FCCP; Shirin Shafazand, MD, FCCP; John P. Griffin, MD, FCCP; Robert Keenan, MD, FCCP; Chris T. Bolliger, MD, FCCP

American Association for Bronchology - Disease Specific Society
American Association for Thoracic Surgery - Medical Specialty Society
American College of Surgeons - Medical Specialty Society
American Society for Therapeutic Radiology and Oncology
Asian Pacific Society of Respirology - Disease Specific Society
Oncology Nursing Society - Professional Association
Society of Thoracic Surgeons - Medical Specialty Society
World Association of Bronchology - Disease Specific Society

This is the current release of the guideline.

This guideline updates a previous version: Beckles MA, Spiro SG, Colice GL, Rudd RM. The physiologic evaluation of patients with lung cancer being considered for resectional surgery. Chest 2003 Jan;123(1 Suppl):105S-14S.

This NGC summary was completed by ECRI on June 30, 2003. The information was verified by the guideline developer on July 25, 2003. This NGC summary was updated by ECRI Institute on November 8, 2007. The updated information was verified by the guideline developer on December 21, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.