Each recommendation is rated based on the levels of evidence (good, fair, poor), net benefit (substantial, moderate, small/weak, none/negative), and the grades of the recommendations (A, B, C, D, I). Definitions are presented at the end of the "Major Recommendations" field.
Multidisciplinary Approach
- All cancer units, treatment facilities, and centers should have a multidisciplinary lung cancer conference that meets on a regular and continuing basis. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
- Multidisciplinary lung cancer teams should consider establishing a multispecialty lung cancer clinic. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
Referral Pattern
- All patients with known or suspected lung cancer should be referred to a multidisciplinary team of physicians or a physician with experience in the management of lung cancer. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
- For patients in whom tissue diagnosis or staging remains incomplete, referral should be to a specialist with expertise in these areas. When completed, the choice of referral may vary with the interventions(s) proposed. Quality of evidence: poor; net benefit: moderate; strength of recommendation: C
- A multidisciplinary group is particularly valuable for management of patients who may be offered multimodality therapy. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
Management Decisions
- Management decisions emanating from the multidisciplinary conference should be guided by locally agreed-on adaptations of clinical practice guidelines or other evidence. Quality of evidence: fair; net benefit: substantial; strength of recommendation: B
- All patients should be evaluated as potential candidates for clinical trials and enrollment should be encouraged. Quality of evidence: poor; net benefit: none/negative; strength of recommendation: I
- A specific coordinator of care should be identified to the patient and caregivers. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
Timetable
- For patients with suspected lung cancer, evaluation, diagnosis, and treatment planning should be expedited. Quality of evidence: fair; net benefit: substantial; strength of recommendation: B
Communication
- Patients with lung cancer should have clear understandable information about their diagnosis, treatment, and possible outcomes. Patients and their families should be offered clear, full, prompt, and culturally appropriate information, preferably in both verbal and written form. Quality of evidence: fair; net benefit: substantial; strength of recommendation: B
- All health professionals involved in the care of the patient should be aware of the management plan. This communication should include the clinical staging, what the patient has been told, and the proposed treatment plan. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
Ongoing Care
- For all patients with lung cancer, explicit guidelines for follow-up and surveillance after the initial treatment should be developed. It should be clear to the patient who will be supervising their ongoing care and surveillance. Patients should be aware of who and how to access assistance for urgent problems. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
- For patients with lung cancer in whom death or a significant change in clinical status occurs, the primary care physician and all management team members should be advised. Likewise, the primary care physician should notify the management team and all interested parties if a change in clinical status of the patient should occur at home. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
Definitions:
Levels of Evidence
In general, good evidence included prospective, controlled, randomized clinical trials, and poor evidence included case series and clinical experience. Trials with fair quality of evidence, for instance, historically controlled trials or retrospective analyses, were somewhere in between.
Grades of Recommendations and Estimates of Net Benefit
The grade of the strength of recommendations is based on both the quality of the evidence and the net benefit of the service (i.e., test, procedure, etc).
Grade A The panel strongly recommends that clinicians routinely provide [the service] to eligible patients. An "A" recommendation indicates good evidence that [the service] improves important health outcomes and that benefits substantially outweigh harms.
Grade B The panel recommends that clinicians routinely provide [the service] to eligible patients. A "B" recommendation indicates at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.
Grade C The panel recommends that clinicians routinely provide [the service] to eligible patients. A "C" recommendation indicates that there was consensus among the panel to recommend [the service] but that the evidence that [the service] is effective is lacking, of poor quality, or conflicting, or the balance of benefits and harms cannot be reliably determined from available evidence.
Grade D The panel recommends against clinicians routinely providing [the service]. A "D" recommendation indicates at least fair evidence that [the service] is ineffective or that harm outweighs benefit.
Grade I The panel concludes that the evidence is insufficient to recommend for or against [the service]. An "I" recommendation indicates that evidence that [the service] is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined, and that the panel lacked a consensus to recommend it.
Net Benefit
The levels of net benefit are based on clinical assessment. Estimated net benefit may be downgraded based on uncertainty in estimates of benefits and harms.
Substantial Benefit: Benefit greatly outweighs harm
Moderate Benefit: Benefit outweighs harm
Small/weak Benefit: Benefit outweighs harm to a minimally clinically important degree
None/negative Benefit: Harms equal or outweigh benefit, less than clinically important
