This is the current release of the guideline.

This guideline updates a previous version: Kvale PA, Simoff M, Prakash UB. Lung cancer. Palliative care. Chest 2003 Jan;123(1 Suppl):284S-311S.

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

1. All lung cancer patients and their families must be reassured that pain can be relieved safely and effectively. All patients should be questioned regularly about their pain, using the patient's self-report of pain and a simple rating scale as the primary source of assessment. Grade of recommendation, 1A
2. For all patients, individualize medications that are used to control pain. Administer medications regularly and treat pain appropriately. Document the effectiveness of pain management at regular intervals during treatment. Grade of recommendation, 1A
3. For all patients with mild-to-moderate pain, manage the pain initially with acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID), assuming there are no contraindications to their use. Use opioids when pain is more severe or when it increases. Grade of recommendation, 1B
4. For any patient, if it is anticipated that there will be a continuous need for opioid medication, meperidine is not recommended. It has a short duration of action, and its metabolite normeperidine is toxic and can cause CNS stimulation resulting in dysphoria, agitation, and seizures. Grade of recommendation, 1B
5. For patients whose pain is not controlled by pure analgesic medications, adjunctive medications such as tricyclic antidepressants, anticonvulsants, and neuroleptic agents will often augment the effects of pure analgesic medications. Grade of recommendation, 1C
6. For all patients, administer medications by mouth because of convenience and cost-effectiveness. In patients with lung cancer who cannot take pain medications by mouth, rectal and transdermal administration are recommended. Administration of analgesics by the intramuscular (IM) route is not recommended because of pain, inconvenience, and unreliable absorption. Grade of recommendation, 1C
7. For all patients receiving opioids, because constipation is common, anticipate it, treat it prophylactically, and constantly monitor it. Grade of recommendation, 1B
8. Encourage all patients to remain active and to care for themselves whenever possible. Avoid prolonged immobilization whenever possible. Grade of recommendation, 1B
9. In patients who have pain associated with muscle tension and spasm, it is recommended that complimentary methods for pain relief such as cutaneous stimulation techniques (heat and cold applications), acupuncture, psychosocial methods of care, and pastoral care be incorporated into the pain-management plan, but not as a substitute for analgesics. Grade of recommendation, 1C
10. For patients with advanced lung cancer, provide palliative radiation therapy to control pain. Palliative chemotherapy to decrease pain and other symptoms is recommended even though the increase in survival may be only modest. Grade of recommendation, 1B
11. In patients with lung cancer who have pain unresponsive to standard methods of pain control, referral to a specialized pain clinic or palliative care consultant is recommended. Grade of recommendation, 1C
12. For all lung cancer patients who complain of dyspnea, it is recommended that they be evaluated for potentially correctable causes, such as localized obstruction of a major airway, a large pleural effusion, pulmonary emboli, or an exacerbation of coexisting COPD or congestive heart failure. If one of these problems is identified, treatment with appropriate methods is recommended. Grade of recommendation, 1C
13. For all lung cancer patients whose dyspnea does not have a treatable cause, opioids are recommended. Also recommended are other pharmacologic approaches such as oxygen, bronchodilators, and corticosteroids. Grade of recommendation, 1C
14. For all lung cancer patients with dyspnea, it is recommended that nonpharmacologic and noninterventional treatments be considered, such as patient and family education, breathing control, activity pacing, relaxation techniques, fans, and psychosocial support. Grade of recommendation, 2C
15. For all lung cancer patients who have troublesome cough, it is recommended that they be evaluated for treatable causes. Grade of recommendation, 1B
16. For all lung cancer patients who have troublesome cough without a treatable cause, it is recommended that opioids be used to suppress the cough. Grade of recommendation, 1B
17. For patients with lung cancer who have pain due to bone metastases, external radiation therapy is recommended for pain relief. A single fraction of 8 Gy is as effective as higher fractionated doses of external radiation therapy for immediate relief of pain. Grade of recommendation, 1A
18. For patients with lung cancer who have pain due to bone metastases, higher fractionated doses of radiation therapy provide a longer duration of pain relief, less frequent need for retreatment, and fewer skeletal-related events than does a single fraction. Grade of recommendation, 1A
19. For patients with lung cancer who have painful bone metastases bisphosphonates are recommended together with external radiation therapy for pain relief. Grade of recommendation, 1A
20. For patients with lung cancer who have painful bone metastases refractory to analgesics, radiation and bisphosphonates, radiopharmaceuticals are recommended for pain relief. Grade of recommendation, 1B
21. In patients with lung cancer who have painful bone metastases to long and/or weight-bearing bones and a solitary well-defined lytic lesion circumferentially involving > 50% of the cortex and an expected survival > 4 weeks with satisfactory health status, surgical fixation is recommended to minimize the potential for a fracture. Intramedullary nailing is the preferred approach, especially for the femur or the humerus. Grade of recommendation, 1C
22. In patients with lung cancer who have symptomatic brain metastases, dexamethasone, 16 mg/d, is recommended during the course of definitive therapy with a rapid taper and discontinuation within 6 weeks of completion of definitive therapy (either surgery or radiation therapy). Grade of recommendation, 1B
23. Patients with non-small cell lung cancer (NSCLC) and an isolated solitary brain metastasis should be considered for a curative resection of the lung primary tumor as long as a careful search for other distant metastases or mediastinal lymph nodes has been carried out and is negative. Grade of recommendation, 1C
24. In patients with no other sites of metastases and a synchronous resectable N0,1 primary NSCLC, resection or radiosurgical ablation of an isolated brain metastasis should be undertaken (as well as resection of the primary tumor). Resection of the isolated solitary brain metastases should be followed by whole-brain radiation therapy (WBRT). Grade of recommendation, 1B
25. For patients with lung cancer who have new onset of back pain, sagittal T1-weighted MRI of the entire spine is recommended for diagnostic purposes. Other diagnostic studies such as plain radiographs, bone scans, or computed tomography (CT) myelograms are not recommended. Grade of recommendation, 1C
26. For patients with lung cancer and epidural spinal cord metastases who are not paretic and ambulatory, prompt treatment with high-dose dexamethasone and radiotherapy is recommended. Grade of recommendation, 1B
27. When there is symptomatic radiographically confirmed compression of the spinal cord, neurosurgical consultation must be sought and, if appropriate, surgery should be performed immediately and followed by radiation for patients with metastatic epidural spinal cord compression and generally good performance status. Grade of recommendation, 1A
28. For all lung cancer patients with large-volume hemoptysis, bronchoscopy is recommended to identify the source of bleeding, followed by endobronchial management options such as argon plasma coagulation (APC), neodymium-doped yttrium aluminium garnet (Nd-YAG) laser, and electrocautery. Grade of recommendation, 1C
29. In lung cancer patients with symptomatic malignant pleural effusions, thoracentesis is recommended as the first drainage procedure for symptom relief. Grade of recommendation, 1C
30. In lung cancer patients with symptomatic pleural effusions that recur after thoracentesis, chest tube drainage and pleurodesis are recommended. Grade of recommendation, 1B
31. In patients with superior vena cava (SVC) obstruction from suspected lung cancer, definitive diagnosis by histologic or cytologic methods is recommended before treatment is started. Grade of recommendation, 1C
32. In patients with symptomatic SVC obstruction due to SCLC, chemotherapy is recommended. Grade of recommendation, 1C
33. In patients with symptomatic SVC obstruction due to NSCLC, stent insertion and/or radiation therapy are recommended. Stents are also recommended for small cell lung cancer (SCLC) or NSCLC symptomatic patients with SVC obstruction who fail to respond to chemotherapy or radiation therapy. Grade of recommendation, 1C
34. For patients with a malignant tracheoesophageal fistula (TEF) or bronchoesophageal fistula, stenting of esophagus, airway, or both should be considered for symptomatic relief. Attempts at curative resection or esophageal bypass of the involved airway and/or the esophagus are not recommended. Grade of recommendation, 1C
35. It is recommended that all patients with lung cancer be evaluated for the presence of depression and, if present, treated appropriately. 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

None provided

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

The comments in the section on pain control were adapted from:

• Jacos A, Carr DB, Payne R. Management of cancer pain. Rockville, MD: Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service, 1994.
• Goudas L, Carr DB, Bloch R. Management of cancer pain. Rockville, MD: Agency for Healthcare Research and Quality, 2001.
• Miaskowski C, Cleary J, Burney R, et al. Guideline for the management of cancer pain in adults and children. Glenview, IL: American Pain Society, 2005.

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: Paul A. Kvale, MD, FCCP; Paul A. Selecky, MD, FCCP; Udaya B. S. Prakash, 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: Kvale PA, Simoff M, Prakash UB. Lung cancer. Palliative care. Chest 2003 Jan;123(1 Suppl):284S-311S.

This NGC summary was completed by ECRI on September 3, 2003. The information was verified by the guideline developer on October 1, 2003. This summary was updated on May 3, 2005 following the withdrawal of Bextra (valdecoxib) from the market and the release of heightened warnings for Celebrex (celecoxib) and other nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on June 16, 2005, following the U.S. Food and Drug Administration advisory on COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). This NGC summary was updated by ECRI Institute on November 29, 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.