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. 2000 Feb 5;320(7231):379.

Managing patients with lung cancer

Effective communication, palliative care, and guidelines are needed

Massimo Costantini 1,2,3,4,5, Irene J Higginson 1,2,3,4,5, Calliope C S Farsides 1,2,3,4,5, Franco Toscani 1,2,3,4,5, Susie Wilkinson 1,2,3,4,5
PMCID: PMC1127155  PMID: 10657345

Editor—We welcome Simmonds's analysis of the management of patients with lung cancer, the “Cinderella of common solid tumours.”1 We believe, however, that he has created two further Cinderellas. The guidelines he cites represent a big advance over previous guidelines because they include a commitment to patient centred care, underpinned by strong evidence supporting communication.2 He does not mention communication, but this is the only route to a clear understanding of what an individual patient would choose. A meta-analysis has concluded that chemotherapy can offer prolonged survival of 1.5-3 months. Such evidence does not, however, inform us of the value of such survival to individual patients.

A recent study showed that although 11% of lung cancer patients would not choose a treatment entailing severe toxicity for a possible extra survival of two years, 6% of patients were prepared to do so for a possible survival of only one week.3 This highlights the importance of providing patients with information of all available options in a manner that is not mediated by the physician's assumption of what should be their preference.

In the case of advanced lung cancer (as in most advanced disease) this must include the option of palliative care, the second Cinderella of Simmonds's editorial.

References

  • 1.Simmonds P. Managing patients with lung cancer. New guidelines should improve standards of care. BMJ. 1999;319:527–528. doi: 10.1136/bmj.319.7209.527. . (28 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.NHS Executive. Guidance on commissioning cancer services. Improving outcomes in lung cancer: the research evidence. Leeds: NHS Executive; 1998. [Google Scholar]
  • 3.Silvestri G, Prichard R, Gilbert Welch H. Preferences for chemotherapy in patients with advanced non-small cell lung cancer: descriptive study based on scripted interviews. BMJ. 1998;317:771–775. doi: 10.1136/bmj.317.7161.771. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 Feb 5;320(7231):379.

Specialist palliative care is needed

Teresa Beynon 1, Victoria Lidstone 1, Claire Sinnott 1, Michael Richards 1

Editor—The role of specialist palliative care was not mentioned in Simmonds's recent editorial on managing patients with lung cancer.1-1 This is of particular concern as one of the main recommendations of the recently published national guidance on improving outcomes in patients with lung cancer is that palliative care should be an integral part of patient management from the outset and that this should be the responsibility of a multiprofessional team that has close links with the lung cancer team.1-2

Patients with lung cancer often have a very poor prognosis, multiple physical symptoms, and psychosocial concerns.1-3 In a recent study of 480 patients attending oncology clinics at Guy's and St Thomas's Hospitals, London, those with lung cancer reported the greatest number and severity of problems (V Lidstone, unpublished data). Referral to a hospital specialist palliative care team has been shown to lead to reductions in the severity of several of the symptoms, including pain, experienced by patients with lung cancer.1-4

Studies from France show that pain management in cancer centres is often suboptimal.1-5

References

  • 1-1.Simmonds P. Managing patients with lung cancer. New guidelines should improve standards of care. BMJ. 1999;319:527–528. doi: 10.1136/bmj.319.7209.527. . (28 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.NHS Executive. Guidance on commissioning cancer services. Improving outcomes in lung cancer: the research evidence. Leeds: NHS Executive; 1998. [Google Scholar]
  • 1-3.Degner LF, Sloan JA. Symptom distress in newly diagnosed cancer patients and as a predictor of survival in cancer. J Pain Symptom Manage. 1995;10:423–431. doi: 10.1016/0885-3924(95)00056-5. [DOI] [PubMed] [Google Scholar]
  • 1-4.Beynon T. Palliative care assessment tool. Palliat Med. 1997;11:57–58. doi: 10.1177/026921639701100109. [DOI] [PubMed] [Google Scholar]
  • 1-5.Larue F, Colleau SM, Brasseur L, Cleeland CS. Multicentre study of cancer pain and its treatment in France. BMJ. 1995;301:1034–1037. doi: 10.1136/bmj.310.6986.1034. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 Feb 5;320(7231):379.

Biomedical literature does not support routine use of laboratory variables as prognostic factors

Joseph Watine 1

Editor—Simmonds in his editorial on managing patients with lung cancer states that, in addition to the extent of the disease and the performance status, several laboratory variables (for example, serum concentrations of sodium and activity of alkaline phosphatase, aspartate aminotransferase, and lactate dehydrogenase) can be used to guide the treatment of patients with small cell lung cancer.2-1

Table.

Prognostic significance of certain laboratory variables in small cell lung cancer according to 52 different studies published from 1981 to 1998

No of studies
Not significant Uncertain significance Significant
Lactate dehydrogenase 17 19 7
Aspartate arninotransferase (+serum glutamic pyruvic transaminase) 10 0 0
Alkaline phosphatase 26 5 3
Sodium concentrations 21 6 6
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We have recently reviewed the biomedical literature generated in this field over the past 20 years,2-2,2-3 using the methods recommended by the International Federation of Clinical Chemistry.2-4 In the table we have summarised the results of the 52 studies that have evaluated the pretherapeutic prognostic significance (in terms of survival) of serum concentrations of sodium and activities of alkaline phosphatase, aspartate aminotransferase, and lactate dehydrogenase in patients with small cell lung cancer. The column labelled “uncertain significance” corresponds to variables that were found significant by authors who had omitted at least one of the following radioclinical variables from their multivariate statistical analysis: weight loss, age, gender, performance status, and extension of the disease. The situation summarised in the table did not change when we tried to identify the laboratory variables that might have an independent prognostic significance in subgroups of patients with small cell lung cancer who have limited or extensive disease, even if distinguishing such subgroups of patients implies a small number of studies for most of the variables.

Simmonds was right in saying that the extent of the disease and the performance status do not allow a perfect distinction between patients who will benefit from therapy and patients who will not.2-5 Doctors should, however, bear in mind that, except perhaps for serum activity of lactate dehydrogenase,2-3 the current biomedical literature does not support the routine use of the laboratory variables cited by Simmonds as additional prognostic factors in patients with small cell lung cancer.

References

  • 2-1.Simmonds P. Managing patients with lung cancer. New guidelines should improve standards of care. BMJ. 1999;319:527–528. doi: 10.1136/bmj.319.7209.527. . (28 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Watine J, Charet X. Do blood cell counts and/or differential have an independent pretherapeutic prognostic value in primary lung cancer? Hematol Cell Ther. 1998;40:99–106. [PubMed] [Google Scholar]
  • 2-3.Watine J. Further comments on prognostic factors of small-cell lung cancer in Okayama lung cancer study group trials. How about a more precise laboratory technique? Acta Med Okayama. 1999;53:99–101. [PubMed] [Google Scholar]
  • 2-4.IFCC Committee on Systematic Reviewing in Laboratory Medicine. Systematic reviewing in laboratory medicine. J IFCC. 1997;9:154–155. [PubMed] [Google Scholar]
  • 2-5.Ihde DC, Pass HI, Glatstein EJ. Small cell lung cancer. In: De Vita VT, Hellman S, Rosenberg SA, editors. Cancer. Principles and practice of oncology. 4th ed. Philadelphia: Lippincott; 1993. pp. 723–758. [Google Scholar]
BMJ. 2000 Feb 5;320(7231):379.

Common international guidelines must be developed

Andrea Ardizzoni 1,2,3,4,5, Francesco Grossi 1,2,3,4,5, Franco Salvati 1,2,3,4,5, Giovanni Silvano 1,2,3,4,5, Leonardo Santi 1,2,3,4,5

Editor—We agree with Simmonds that evidence based guidelines for clinical practice should help clinicians make better decisions, thereby reducing inappropriate variation and improving patient care.3-1 The publication by different organisations of guidelines on the same subject, but with substantial differences in their recommendations, may, however, increase instead of reduce variability in patient care. The guidelines of the clinical oncology information network (COIN) for the non-surgical management of lung cancer, recently published by the Royal College of Radiologists, exemplify this variability.3-2 These guidelines for clinical practice are different from others developed in the same field by organisations in different countries. They contain three statements that are difficult to justify on the basis of available scientific evidence. 3-3–3-5

(1) “Patients with good performance status who have locoregionally advanced disease (stage III) should be considered for radical radiotherapy.”

A number of prospective randomised studies and a meta-analysis have shown the value of adding chemotherapy to radiation in locally advanced non-small cell lung cancer. Currently, at least three guidelines recommend the use of combined chemoradiation as standard treatment for selected patients.

(2) “In patients with advanced non-small cell lung cancer (stage IIIB and IV) chemotherapy should normally be offered in the context of a clinical trial.”

Numerous prospective randomised trials and a meta-analysis have shown a significant survival benefit with platinum based chemotherapy. In addition, recent randomised studies indicate a clear improvement in the quality of life with chemotherapy compared with best supportive care.

Again, contrary to the COIN guidelines, American, Canadian and European guidelines suggest the use of platinum based chemotherapy in selected patients even outside clinical trials.

(3) “Consolidation thoracic radiotherapy increases local control and survival in patients with limited disease who have achieved a complete response to chemotherapy.”

The meta-analysis quoted to support this statement shows that the addition of thoracic irradiation to chemotherapy improves survival in patients with limited small cell lung cancer irrespective of the timing of radiation and the type of response to chemotherapy. There is therefore no rationale to limit the use of thoracic irradiation to patients with complete response to chemotherapy. The European state of the art (START) oncology guidelines say that in patients with stage III disease chemotherapy and radiotherapy is standard treatment on a type 1 level of evidence.

Differences between the recommendations of British radiologists and European and North American organisations for the treatment of lung cancer are striking and not justified on the basis of available scientific evidence. The development of common international and multidisciplinary clinical guidelines would be a step forward in further reducing variation and improving patient care.

References

  • 3-1.Simmonds P. Managing patients with lung cancer. New guidelines should improve standards of care. BMJ. 1999;319:527–528. doi: 10.1136/bmj.319.7209.527. . (28 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-2.Royal College of Radiologists' Clinical Oncology Information Network. Guidelines on the non-surgical management of lung cancer. Clin Oncol. 1999;11:S1–53. [PubMed] [Google Scholar]
  • 3-3.American Society of Clinical Oncology Clinical. Practice guidelines for the treatment of unresectable non-small-cell lung cancer. J Clin Oncol. 1997;15:2996–3018. doi: 10.1200/JCO.1997.15.8.2996. [DOI] [PubMed] [Google Scholar]
  • 3-4.Evans WK, Newman T, Graham I, Rusthoven JJ, Logan D, Shepherd FA, et al. Lung cancer practice guidelines: lessons learned and issues addressed by the Ontario Lung Cancer Disease Site Group. J Clin Oncol. 1997;15:3049–3059. doi: 10.1200/JCO.1997.15.9.3049. [DOI] [PubMed] [Google Scholar]
  • 3-5.State of the Art Oncology in Europe: http://www.cancereurope.net/start/web/home.cfm
BMJ. 2000 Feb 5;320(7231):379.

Author's reply

Peter Simmonds 1

Editor—The COIN guidelines focus on the treatment of patients with lung cancer with chemotherapy and radiotherapy and therefore do not address in detail other means of achieving symptom control and palliative care. The need for effective communication with patients is, however, highlighted and it is emphasised that care should be provided by a coordinated multidisciplinary team including specialist palliative care services.4-1

Watine and Ardizzoni et al have highlighted some of the differences between the COIN guidelines and similar American and European guidelines. It is important that guidelines for clinical practice are relevant to the context of those practitioners for whom they are intended. Important differences in evidence based guidelines are, however, a source of concern. The reason may be that they are derived from different evidence bases, there are differences in the interpretation of the outcomes, quality, or generalisability of the primary research, or there is insufficient evidence necessitating development of consensus guidelines. I agree with the suggestion that the development of common international multidisciplinary clinical guidelines would be helpful in further reducing inappropriate variation in treatment and improving patient care.

Footnotes

p.d.simmonds@soton.ac.uk

References

  • 4-1.Royal College of Radiologists' Clinical Oncology Information Network. Guidelines on the non-surgical management of lung cancer. Clin Oncol. 1999;11:S1–53. [PubMed] [Google Scholar]

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