NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.

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1 bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: Pathway last updated: 23 August 2016 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved

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3 1 Person with suspected lung cancer No additional information 2 Symptoms and signs indicating urgent chest X-ray and urgent and immediate referral Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they: have chest X-ray findings that suggest lung cancer or are aged 40 and over with unexplained haemoptysis. Offer a chest X-ray to assess for lung cancer in people aged 40 and over if they have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 or more of the following unexplained symptoms: cough fatigue shortness of breath chest pain weight loss appetite loss. Consider an urgent chest X-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 40 and over with any of the following: persistent or recurrent chest infection finger clubbing supraclavicular lymphadenopathy or persistent cervical lymphadenopathy chest signs consistent with lung cancer thrombocytosis. Send a copy of the radiologist's report to a designated member of the lung cancer MDT (usually the chest physician) when a chest X-ray incidentally suggests lung cancer. Ensure the MDT has a mechanism for following up these reports with the patient's GP. Page 3 of 10

4 NICE has produced pathways on respiratory conditions and suspected cancer recognition and referral. Quality standards The following quality statement is relevant to this part of the pathway. 2. Appointment with a cancer specialist 3 Information and support Raise awareness of the symptoms and signs of lung cancer through coordinated campaigning. Ensure that a lung cancer clinical nurse specialist is available at all stages of care to support patients and carers. Effective communication with patients Find out what the patient knows about their condition without assuming a level of knowledge. Offer accurate and easy-to-understand information and ensure all communications are worded to assist understanding. Explain treatment options (including potential survival benefits, side effects and effect on symptoms) in a private environment, with the support of carers and the time to make an informed choice. Consider tailor-made decision aids to help patients understand probable outcomes, weigh up possible benefits and harms and make decisions about treatments. Offer patients a record of all discussions and a copy of correspondence with other healthcare professionals, but avoid giving bad news by letter. Only give bad news by phone in exceptional circumstances. When appropriate, sensitively offer to discuss end-of-life care. If possible, avoid leaving this until the terminal stages, but respect the patient's choice if they do not wish to confront future issues. Ensure patients know how to contact the lung cancer clinical nurse specialist between scheduled hospital visits. Page 4 of 10

5 Effective communication among the MDT Document discussions with the patient about end-of-life care, particularly about the patient's specific concerns, their understanding of the prognosis, and important values and preferences for care and treatment. Share information between healthcare professionals about the management plan, what the patient has been told and has understood, any problems, any advance decisions and the involvement of other agencies. Discuss care of patients with a working diagnosis of lung cancer at a lung cancer MDT meeting. Quality standards The following quality statements are relevant to this part of the pathway. 1. Public awareness 3. Chest X-ray report 4. Lung cancer clinical nurse specialist 5. Holistic needs assessment 4 Advice on smoking cessation Advise patients to stop smoking as soon as lung cancer is suspected and tell them that smoking increases the risk of complications after surgery. Offer nicotine replacement therapy and other therapies in line with NICE guidance in the smoking pathway. Do not postpone surgery to allow patients to stop smoking. 5 Diagnosis and staging See Lung cancer / Diagnosis and staging of lung cancer Page 5 of 10

6 6 Treatment and supportive and palliative care See Lung cancer / Treatment and supportive and palliative care for lung cancer 7 Follow-up Offer an initial specialist follow-up appointment within 6 weeks of completing treatment to discuss ongoing care. Offer regular appointments thereafter, rather than relying on patients requesting appointments when they experience symptoms. Offer protocol-driven follow-up led by a lung cancer clinical nurse specialist as an option for patients with a life expectancy of more than 3 months. Collect the opinion and experience of lung cancer patients and carers to improve the delivery of services. Ensure patients receive feedback on any action taken as a result of such surveys. Quality standards The following quality statement is relevant to this part of the pathway. 14. Optimal follow-up regime 8 Service organisation Provide rapid access clinics where possible for the investigation of suspected lung cancer, because they are associated with faster diagnosis and less patient anxiety. All cancer units/centres should have one or more trained lung cancer clinical nurse specialists to see patients before and after diagnosis, to provide continuing support and to facilitate communication between the secondary care team (including the MDT), the patient's GP, the community team and the patient. Their role includes helping patients to access advice and support whenever they need it. Every cancer network should have rapid access to PET-CT scanning. Every cancer network should have at least one centre with EBUS and/or EUS. Page 6 of 10

7 Audit the local test performance of non-ultrasound-guided TBNA, EBUS and EUS-guided FNA. Every cancer network should ensure that patients have rapid access to a team capable of providing interventional endobronchial treatments. Quality standards The following quality statements are relevant to this part of the pathway. 4. Lung cancer clinical nurse specialist 15. Palliative interventions 9 NICE pathway on patient experience in adult NHS services See Patient experience in adult NHS services Page 7 of 10

8 Glossary EEG electroencephalography BIS Bispectral Index Consistent with the finding has characteristics that could be caused by many things, including cancer EBUS endobronchial ultrasound EUS endoscopic ultrasound EGFR-TK epidermal growth factor receptor tyrosine kinase FNA fine needle aspiration MDT multidisciplinary team NSCLC non-small-cell lung cancer Page 8 of 10

9 Persistent The continuation of specified symptoms and/or signs beyond a period that would normally be associated with self-limiting problems. The precise period will vary depending on the severity of symptoms and associated features, as assessed by the healthcare professional. SCLC small-cell lung cancer TBNA transbronchial needle aspiration Unexplained symptoms or signs that have not led to a diagnosis being made by the healthcare professional in primary care after initial assessment (including history, examination and any primary care investigations) Sources Suspected cancer: recognition and referral (2015) NICE guideline NG12 Lung cancer: diagnosis and management (2011) NICE guideline CG121 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Page 9 of 10

10 Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT Page 10 of 10