(Chest. 2007; 132:20S-22)
© 2007 American College of Chest Physicians
Introduction: Diagnosis and Management of Lung Cancer*
ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)
W. Michael Alberts, MD, MBA, FCCP
Correspondence to: W. Michael Alberts, MD, MBA, FCCP, Chief Medical Officer, H. Lee Moffitt Cancer Center and Research Institute, Professor of Medicine, University of South Florida College of Medicine, 12902 Magnolia Dr, Tampa, FL; e-mail: Michael.Alberts{at}moffitt.org
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Introduction
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To reprise but paraphrase the opening line of the Introduction to the First Edition of the Guidelines: The numbers are still staggering. It is projected that in 2007, cancer of the lung will be diagnosed in 213,380 individuals in the United States (up from 169,400 in 2002; 114,760 men and 98,620 women).1 More disconcerting is that 160,390 individuals (up from 154,900 in 2002) will succumb to this disease (89,510 men and 70,880 women) during the year.1 Interestingly, however, the death rate (as opposed to raw numbers) for lung cancer in men has dropped on average by 1.9%/yr from 1991 to 2003. Unfortunately, the death rate in women is up by 0.3% each year from 1995 to 2003. If these current trends continue, the incidence of lung cancer will be identical for men and women during the next decade.
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Mortality
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Lung cancer continues to be the leading cause of cancer deaths in both men and women in the United States. Deaths from lung cancer in women surpassed those due to breast cancer in 1987 and are expected to account for about 26% of all female cancer deaths in 2006.1 Thirty-one percent of cancer deaths in men are attributable to lung cancer.1 Lung cancer causes more deaths than the next four most common cancers combined (colon, n = 52,180; breast, n = 40,910; pancreas, n = 33,370; and prostate, n = 27,050).1
Once again, the international statistics are no more comforting (and in many cases, more ominous). Approximately 1.2 million people worldwide died of lung cancer in 2002.2 It is interesting to note that there are more active cigarette smokers in China than there are people in the United States. The full effect of the worldwide tobacco epidemic is yet to come.
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Advances Form the Basis for the Second Edition
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Despite the ominous statistics, research continues and, fortunately, significant advances have occurred in the 4 years since the First Edition of the Guidelines. This serves as the impetus for the updated recommendations. For example, a number of studies have confirmed a small but significant increase in 5-year survival when adjuvant chemotherapy is administered to selected postsurgical patients.3 Discussions of the pros and cons of adjuvant chemotherapy are recommended for some categories of fully resected patients with non-small cell lung cancer.
Targeted chemotherapy has been shown to provide a significant mortality benefit in selected clinical situations. Bevacizumab, when added to carboplatin and paclitaxel as first-line chemotherapy, yielded a 2-month increase in median survival (10.2 months vs 12.5 months, p = 0.0075).4 Erlotinib, when administered to patients for whom first-line treatment had failed, provided a 2-month increase in survival (4.7 months vs 6.7 months, p < 0.0001).5 It is hoped that by the time of the Third Edition of these Guidelines, the promise of molecular oncology, pharmacogenomics, and personalized therapy will be more apparent.
New chapters have been included in the Second Edition reflecting the feedback received after the First Edition. Chapters on bronchoalveolar carcinoma, integrative oncology, and special topics in pathology are welcome additions to the comprehensive Guidelines. The maturation of several newer diagnostic modalities such as endoscopic ultrasound-guided biopsy and positron emission tomography permit them to be integrated into diagnostic recommendations and algorithms. A broadly expanded chapter on the evaluation of the solitary pulmonary nodule will be of value to the clinician.
Controversial issues, such as lung cancer screening, are addressed and extensively discussed. Observational data have been published suggesting that CT screening can identify lung cancers when they are small and predominantly stage I.6 It is hoped that the randomized controlled trials currently underway will provide better evidence relating to the important issue of mortality benefit. In the meantime, however, the preferences of a fully informed patient must be weighed heavily. The phrase "fully informed" cannot be overstated. The pros and cons of lung cancer screening are difficult to explain to patients (much less comprehend) yet are crucial to making an informed choice. The Guidelines recommend that that low-dose CT not be used to screen for lung cancer except in the context of a well-designed clinical trial.
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The Real Culprit
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As mentioned in the First Edition, one must point out that the effort evidenced in this publication would not be necessary but for the real culprit, namely tobacco and tobacco products. Tobacco use is the leading cause of preventable death in this country and accounts for one of every five deaths.7 Half of regular smokers die prematurely of a tobacco-related disease.8 Cigarette smoking accounts for approximately 90% of all lung cancer cases in the United States and other countries where cigarette smoking is common.9 Not to minimize the efforts of clinicians and clinical researchers, it is clear that lung cancer is largely a preventable disease. Elimination of tobacco use is the single most effective method available to address the dismal statistics associated with lung cancer.
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Lung Cancer Guidelines Project
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In light of the continuing prevalence of lung cancer and the modest yet significant advances in the field, the American College of Chest Physicians (ACCP) through the Health and Science Policy Committee commissioned the development of this Second Edition of the Diagnosis and Management of Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines. This project was launched in the hope that a systematic review, evaluation, and synthesis of the published literature, along with expert opinion and consensus when necessary, would lead to a series of recommendations that would assist physicians in achieving the best possible outcome for their patients given the knowledge and capabilities available at this time.
The Second Edition of the Guidelines has employed the new ACCP grading system.10 This grading system classifies recommendations as strong (grade 1) or weak (grade 2) according to the balance among benefits, risks, burdens, and possibly cost, and the degree of confidence in estimates of benefits, risks, and burdens. The system classifies the quality of evidence as high (grade A), moderate (grade B), or low (grade C) according to factors that include the study design, the consistency of the results, and the directness of the evidence. This system was formulated to be simple, transparent, explicit, and consistent with current methodologic approaches to the grading process.
As more fully discussed in the "Methodology" chapter, some of the clinical practice guideline recommendations within this document are appropriate to serve as the basis for performance measures. Criteria for selecting such recommendations are two tiered. First, the evidence and benefits need to be sufficiently strong for the recommendations to have a 1A grade. The second tier of criteria includes the following: (1) practicality for ACCP members and their patients, (2) importance, (3) scientific acceptability, (4) usability, and (5) feasibility. The identified recommendations will be forwarded to the American Medical Association Physicians Consortium for Quality Improvement for consideration for development into performance measures and, eventually, submitted to the National Quality Forum for potential endorsement.
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Thank You
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The effort expended on this project by many individuals has been truly heroic. The voluntary effort of the Executive Committee, the chapter editors, the writing committees, and the review panels in support of this publication and our patients has been nothing less than impressive. I am very pleased with the final product and hope that it proves to be of benefit to you and your patients.
Special thanks goes to Gene Colice, MD, as Vice-Chair of the Lung Cancer Guidelines Project, and Doug McCrory, MD, as the principal investigator with the Duke University Evidence-based Practice Center. Both devoted countless hours, nights, and weekends over the past 2 years to ensure the success of the project. Members of the Health and Science Policy Committee, the Thoracic Oncology Network, and the ACCP Board of Regents deserve recognition for their review and editing of the final manuscript. The true driving force, however, behind this effort has been Julia Heitzer, MS, and Sandra Zelman Lewis, PhD, who, as project managers, have brought the project to this point through sheer effort and diplomatic prodding. A thank you is certainly in order.
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Footnotes
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The author has no conflicts of interest to disclose.
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References
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- Jemal, A, Siegel, R, Ward, E, et al (2007) Cancer statistics, 2007. CA Cancer J Clin 57,43-66[Abstract/Free Full Text]
- Parkin, DM, Bray, F, Ferlay, J, et al Global cancer statistics, 2002. CA Cancer J Clin 2005;55,74-108[Abstract/Free Full Text]
- Visbal, AL, Leighl, NB, Feld, R, et al Adjuvant chemotherapy for early-stage non-small cell lung cancer. Chest 2005;128,2933-2943[CrossRef][Medline]
- Sandler, AB, Gray, R, Perry, MC, et al Paclitaxel-carboplatin alone or with bevacizumab for non-small-cell lung cancer. N Engl J Med 2006;355,2542-2550[Abstract/Free Full Text]
- Shepard, FA, Rodrigues-Pereira, J, Ciuleanu, T, et al Erlotinib in previously treated non-small-cell lung cancer. N Engl J Med 2005;353,123-132[Abstract/Free Full Text]
- Henschke, CI, Yankelevitz, DF, Libby, DM, et al Survival of patients with stage I lung cancer detected on CT screening. N Engl J Med 2006;355,1763-1771[Abstract/Free Full Text]
- Centers for Disease Control and Prevention, Annual smoking attributable mortality, years of potential life lost, and productivity losses: United States 1997–2001. MMWR Morb Mortal Wkly Rep 2005;54,625-628[Medline]
- Cokkinides, V, Bandi, P, Ward, E, et al Progress and opportunities in tobacco control. CA Cancer J Clin 2006;56,135-142[Abstract/Free Full Text]
- Peto, R, Lopez, AD, Boreham, J, et al Mortality from smoking in developed countries 1950–2000. Indirect estimates from national vital statistics. 1994 Oxford University Press. Oxford, England:
- Guyatt, G, Gutterman, D, Baumann, MH, et al Grading strength of recommendations and quality of evidence in clinical guidelines. Chest 2006;128,174-181
This article has been cited by other articles:
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F. W. Grannis Jr, W. M. Alberts, and D. Addrizzo-Harris
There Are Major Problems With the American College of Chest Physicians Second Lung Cancer Guidelines
Chest,
April 1, 2008;
133(4):
1049 - 1051.
[Full Text]
[PDF]
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Introduction
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