Diagnosis and Management of Lung Cancer, 3rd ed: …

1 CHEST Supplement Diagnosis AND Management OF LUNG CANCER, 3RD ED: ACCP GUIDELINES. Executive Summary Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Frank C. Detterbeck, MD, FCCP; Sandra Zelman Lewis, PhD; Rebecca Diekemper, MPH;. Doreen J. Addrizzo-Harris, MD, FCCP; and W. Michael Alberts, MD, MBA, FCCP. CHEST 2013; 143(5)(Suppl):7S 37S and it is now a vibrant field with a rapid pace of new information. The explosion of literature makes Abbreviations: ACCP 5 American College of Chest Physicians; it difficult for anyone to stay current. With more AFB 5 autofluorescence bronchoscopy; APW 5 Aortopulmonary insight comes the identification of many nuances Window; BSC 5 best supportive care; CIS 5 carcinoma in situ; that are important to correctly understand new stud- CPET 5 cardiopulmonary exercise test; CXR 5 chest radiograph; ies and choose the optimal treatments for patients.

2 Dlco 5 diffusing capacity for carbon monoxide; EBUS 5 endo- Lung cancer has evolved to where it takes a team of bronchial ultrasound; ECOG 5 Eastern Cooperative Oncology Group; EGFR 5 epidermal growth factor receptor; ES 5 exten- individuals, each with lung cancer expertise within sive stage; FA 5 fine needle aspiration; GGO 5 ground glass opacity; their specialty, to be able to provide the necessary IASLC 5 International Association for the Study of Lung Can- up-to-date knowledge base. The crucial aspect here cer; LC III 5 3rd edition of the ACCP Lung Cancer Guidelines; is not to simply have multiple specialties but to LDCT 5 low-dose CT; LS 5 limited stage; LUL 5 left upper lobe;. develop a forum for ongoing interaction, so that the LVRS 5 lung volume reduction surgery; MFLC 5 multifocal lung cancer; MPE 5 malignant pleural effusion; NA 5 needle aspira- individuals think and function as a team, making tion; NLST 5 National Lung Cancer Screening Trial; NRS 5 numer- decisions collectively.

3 Such integration and collab- ical rating scale; NSAID 5 nonsteroidal antiinflammatory drug; oration allow collective knowledge and judgment to NSCLC 5 non-small cell lung cancer; PET 5 positron emission be brought to bear on caring for patients. Even for tomography; PPO 5 predicted postoperative; PS 5 performance such a team, however, staying abreast of advances is status; QOL 5 quality of life; RCT 5 randomized controlled trial;. RT 5 radiotherapy; SBRT 5 stereotactic body radiation ther- challenging. apy; SCLC 5 small cell lung cancer; SVC 5 superior vena cava; Evidence-based guidelines are intended to make SWT 5 shuttle walk test; TBNA 5 transbronchial needle aspiration; the process of providing up-to-date care easier. The TRT 5 thoracic radiotherapy; TTNA 5 transthoracic needle aspi- third edition of the American College of Chest Physi- ration; VAS 5 visual analog scale; VATS 5 video-assisted thoracic cians (ACCP) Lung Cancer Guidelines (LC III) is a surgery; VEGF 5 vascular endothelial growth factor; o2max 5 max- imal oxygen consumption; WHO 5 World Health Organization; systematic, extensive, comprehensive review of the WLB 5 white light bronchosopy literature, a structured interpretation of the data, and practical patient Management recommendations.

4 The LC III panelists were selected based on expertise and volunteered an astounding number of hours to care- Lung cancer causes as many deaths as the next four leading causes of cancer deaths combined. In the 1. fully and systematically provide the basis for and, finally, produce the guidelines. The result is a prod- developing world, which has seen a dramatic increase uct that can be accessed superficially to quickly find in the rate of smoking, the impending number of guideline statements relevant to a particular clinical deaths from this disease is staggering. Although the issue or more in depth by reviewing the data tables incidence and death rate in the United States has and reading the individual articles. The organized been declining since around 2000, lung cancer is pro- process to produce the guidelines helps to ensure jected to remain by far the leading cause of cancer that it is not biased and is representative of the cur- deaths for many decades.

5 Rent state of knowledge. The LC III documents rep- For many years, lung cancer was a relatively neglected resent a distillation of thousands of hours to make the disease, shrouded in pessimism and with little research insights more easily accessible to the clinicians on the funding. However, many advances have occurred, front lines. CHEST / 143 / 5 / MAY 2013 SUPPLEMENT 7S. Downloaded From: on 12/13/2013. Nevertheless, implementation of the guidelines possible in that setting. The LC III guidelines were requires some effort. They cannot provide a simple designed to provide enough details to facilitate recipe for treatment. Clinical judgment is needed such local adaptation in an efficient manner. This to assess and balance the many factors that go into executive summary provides a brief synopsis of each clinical decision-making.

6 How well do the patients article, highlights the major points, and lists the from whom the data are derived match the patient recommendations. for whom a Management plan is being developed? How strong and consistent are the data, and how heavily should other factors or patient preferences Methodology for Development influence the plan? The essence of clinical judg- of Guidelines for Lung Cancer ment is being able to weigh the strength of the many factors that each patient brings to decision- There have been major advances in the clinical sci- making. The LC III guidelines are designed to impart ence of lung cancer. There have also been major insight into these matters to enhance clinical deci- advances in methodologic science. The ACCP has sion making and not merely present a relatively rigid been at the forefront of these advances and is com- algorithm.

7 Mitted to continuing to evolve the process of litera- A difficulty in developing guidelines is that imple- ture review, data extraction, and guideline development. mentation must also be tailored to the local setting. With the advancement of methodologic techniques, In some countries or institutions, certain tests or pro- content experts and methodologists must work hand cedures may not be available. On a more subtle level, in hand to bring the best each has to offer to bear on although a test may sometimes be available, one cannot the process. Because resources are not unlimited, and assume that the results in every clinical setting match practical aspects and logistics present challenges, how those of the published literature. The best way to to achieve this collaboration was a process that con- implement guidelines is to thoughtfully tailor them tinued to evolve during the development of LC III.

8 To the local setting. This requires assembling the local guidelines. We were fortunate to have the participa- team of specialists and critically reviewing the major tion of a small but growing number of individuals guideline recommendations and the local strengths who have content expertise as well as formal method- and challenges. This allows the development of a ology training. For each article, a methodologist was locally adapted system of care that can significantly assigned and involved during the process of research streamline the process of care and ensure that patients and guideline development. are receiving thoughtful care to the highest degree Manuscript received September 24, 2012; revision accepted November 30, 2012. Epidemiology of Lung Cancer Affiliations: From the Department of Thoracic Surgery (Dr Detterbeck), Yale University School of Medicine, New Haven, The epidemiology of lung cancer is an active field.

9 CT; the American College of Chest Physicians (Dr Lewis and Researchers in the area of molecular epidemiology Ms Diekemper), Northbrook, IL; the Pulmonary Division (Dr Addrizzo-Harris), New York University School of Medicine, are making advances in the identification of bio- New York, NY; and the H. Lee Moffitt Cancer Center (Dr Alberts), markers of risk and for early detection, although these Tampa, FL. are not yet mature enough for clinical application. Funding/Sponsors: The development of this guideline was supported primarily by the American College of Chest Physicians. Cigarette smoking remains the predominant risk The lung cancer guidelines conference was supported in part by factor for lung cancer. A dramatic increase in deaths a grant from the Lung Cancer Research Foundation.

10 The publica- from lung cancer is anticipated in the developing tion and dissemination of the guidelines was supported in part by a 2009 independent educational grant from Boehringer Ingelheim world, given the current high rate of smoking in these Pharmaceuticals, Inc. regions. This will have significant social and economic COI grids reflecting the conflicts of interest that were current as impact. of the date of the conference and voting are posted in the online supplementary materials. Although smoking is the major risk factor, a better Disclaimer: American College of Chest Physician guidelines are understanding of the risk of developing lung cancer intended for general information only, are not medical advice, is needed, particularly with the advent of screening and do not replace professional medical care and physician advice, which always should be sought for any medical condition.