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Glasgow, Scotland, UK
Dr. Milroy is Consultant Respiratory Physician, Stobhill Hospital.
Correspondence to: Robert Milroy, MD, FRCP, Department of Respiratory Medicine, Stobhill Hospital, 133 Balornock Rd, Glasgow G21 3UW, Scotland, UK; e-mail: robert.milroy{at}northglasgow.scot.nhs.uk
Lung cancer continues to be the lead cancer in the United States of America. It is projected that in 2006, lung cancer will be diagnosed in > 174,000 individuals; and although the death rate for lung cancer in men has dropped over the last decade, the death rate in women and the overall death rate continue to rise. The increasing prevalence of smoking worldwide will result in a lung cancer epidemic in the coming decades. Guidelines are:
designed to help practitioners assimilate, evaluate and implement the increasing amount of evidence on best current practice. They are neither a text book or a cookbook but when there is evidence of variation in practice which affects patient outcomes and a strong research base that provides evidence of effective practice, guidelines can assist doctors and other healthcare professionals in making decisions about appropriate and effective care for their patients.1
In lung cancer, there is clear evidence of variations in practice and suboptimal processes of care and underutilization of treatments.2 In addition, there is certainly a strong research base in lung cancer, and many guidelines have already been produced.34
The American College of Chest Physicians (ACCP) evidence-based lung cancer guideline project was launched in the hope that a systematic review, evaluation, and synthesis of the most recent published literature along with expert opinion and consensus, when necessary, would lead to an up-to-date series of recommendations that would assist physicians in achieving the best possible outcome for their lung cancer patients. The guidelines task force melded the best characteristics of several different grading systems to create a more user-friendly and transparent new grading system for producing recommendations.56
This new grading system uses only two dimensions (the ratio of benefit to harm [risks/burdens], and the quality of the evidence) and offers only two types of recommendations (strong or weak).7 It is this interface between the quality of the evidence and the balance of benefit to harm that determines the strength of recommendation, with a 1A recommendation being the strongest. These guidelines include strong recommendations on the basis of significant differences between the ratio of benefit to harm even when the quality of the evidence is low or very low.7
In comparison to the original ACCP lung cancer guidelines,8 the Second Edition published as a Supplement to this issue is a more extensive guideline and includes new additional chapters covering important areas such as surgical pathology, bronchioloalveolar lung cancer, and integrative oncology.7 The chapter on integrative oncology addresses important aspects of palliative care (although the evidence base for making recommendations is currently not strong). The controversial area of lung cancer screening is also extensively discussed. In addition, funding was secured to complete systematic reviews of the literature in five new topic areas: evaluations of solitary pulmonary nodules and management of all stages of non-small cell lung cancer (I and II, IIIA, IIIB, and IV). Advances in this Second Edition include stronger recommendations in relation to adjuvant chemotherapy as well as the maturation of several newer diagnostic modalities including endoscopic ultrasound-guided biopsy and positron emission tomography, which permit integrated diagnostic recommendations.
This updated guideline represents a comprehensive overview of lung cancer covering five broad areas in relation to this disease, including assessment, treatment, and palliative care. First of all, an important general discussion about guideline methodology is included. There are then detailed chapters covering epidemiology, chemoprevention, screening for lung cancer and surgical pathology. The chapter on screening for lung cancer is also complimented by two excellent chapters covering management of patients with pulmonary nodules, which are both common and vexing problems.
There are three excellent chapters covering diagnosis, general evaluation, and then specifically physiologic evaluation in potential presurgical patients. The guidelines then thoroughly cover both noninvasive and invasive staging of lung cancer. An enthusiastic overview covering bronchial intraepithelial neoplasia/early central airways cancer follows.
The guideline continues with detailed chapters covering the treatment of all stages of non-small cell and small cell lung cancer. A chapter is also devoted to special treatment issues in lung cancer, including pancoast tumors, T4,N0/1 tumors, satellite nodules in the same lobe, and synchronous and metachronous tumors, as well as multiple primary lung cancers and solitary brain and adrenal metastases. This is particularly helpful to the clinician facing management problems with such difficult and grey cases.
Subsequently there are two comprehensive chapters covering complementary therapies and integrative oncology, as well as follow-up and surveillance recommendations for lung cancer patients following curative intent therapy. Finally there are two clear, accurate and comprehensive chapters covering palliative care in lung cancer, quality of life measurements, and bereavement for end-of-life care in patients with lung cancer.
However, are lung cancer guidelines invariably beneficial to all patients? The most important limitation of guidelines is that recommendations may be wrong for an individual patient. Recommendations for or against an intervention, in individual patients, will involve subjective value judgements of benefit vs harm, even when data appear certain.9 In addition, guideline recommendations may not specifically take into account comorbidity or patient wishes. Inflexible guidelines can harm by constraining clinicians’ ability to tailor care to an individual patient’s circumstances.
Furthermore, in health-care services with fixed and limited resources, social value judgments in relation to implementation of guideline recommendations play a critical role if resources are to be distributed fairly and efficiently.1011 The UK National Institute for Clinical Excellence uses the cost per quality-adjusted life-year to address cost issues and to undertake comparative economic evaluations. Similarly, an ACCP task force has considered this complex and controversial area.12
Despite the above reservations in relation to guidelines in general, the ACCP lung cancer guideline project group most certainly have achieved their goal to produce updated, evidence-based, clinically relevant guidelines for physicians and other health-care providers managing the care of patients with lung cancer and those who are at risk for lung cancer. There is no doubt that publication of the Second Edition of these lung cancer guidelines in this Supplement of CHEST7 represents an important addition to the lung cancer guidelines armamentarium, and will result in further improvements in the processes of care, treatments, and outcomes for lung cancer patients, not only in the United States but throughout the rest of the world.
Footnotes
The author has no conflict of interest to disclose.
References
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