NICE has issued updated guidelines on the diagnosis and management of lung cancer, which include new recommendations on intrathoracic lymph node assessment, brain imaging in non-small-cell lung cancer (NSCLC), and radical radiotherapy for NSCLC, as well as new guidance on chemoradiotherapy and surgery for stage IIIA-N2 NSCLC and thoracic radiotherapy and prophylactic cranial irradiation for small-cell lung cancer (SCLC).
Key recommendations include:
- PET-CT is preferred for intrathoracic lymph node assessment after CT for nodes
- PET-CT followed by EBUS‑TBNA and/or EUS‑FNA for nodes ≥10.
- Contrast-enhanced brain CT for stage II NSCLC.
- Contrast-enhanced brain MRI for stage III NSCLC.
- Where lobectomy is not performed, offer radical radiotherapy with stereotactic ablative radiotherapy (SABR) or sublobar resection.
- If SABR is contraindicated, offer conventional or hyperfractionated radiotherapy.
- For stage IIIA or IIIB NSCLC patients who cannot tolerate or who decline chemoradiotherapy, consider radical radiotherapy.
- Follow the SABR Consortium guidance on fractionation.
- For conventionally fractionated radical radiotherapy, administer 55 Gy in 20 fractions over four weeks or 60-66 Gy in 30-33 fractions over 6-6½ weeks.
- Do not offer neo-adjuvant treatment for operable stage I-II NSCLC outside of clinical trial.
- Consider chemoradiotherapy with surgery (3-5 weeks later) for operable stage IIIA-N2 NSCLC.
- Consider thoracic radiotherapy with prophylactic cranial irradiation for extensive-stage SCLC with partial or complete response to chemotherapy within the thorax and at distant sites.
- Consider prophylactic cranial irradiation for extensive-stage disease SCLC and WHO performance status 0 to 2, if the disease has responded to first-line treatment.
NICE has produced algorithms covering systemic treatment options for stage IIIB and IV non-squamous (adenocarcinoma, large cell undifferentiated) cancer and NSCLC (not otherwise specified), and for stage IIIB and IV squamous NSCLC.
Recommendations are also provided in relation to EGFR-TK status, ALK gene rearrangement, PDL1 status, and ROS1 positivity.