Minimising the number of steps in a diagnosis and staging pathway and completing them efficiently will reduce delays in care. NICE’s guideline on lung cancer makes a number of recommendations that optimise the diagnostic pathway and allow flexibility for managing a range of people that may present with symptoms of lung cancer.
Pathological confirmation and staging
NICE’s guideline on lung cancer and quality standard on lung cancer state that, when taking samples in people with suspected lung cancer, they should be adequate to permit pathological diagnosis, including tumour subtyping and assessment of predictive markers. A predictive cancer marker is anything present in or produced by cancer cells or other cells of the body in response to cancer. They can provide information on how aggressive the cancer is and whether it could be treated with a targeted therapy. Obtaining a pathological diagnosis and assessment of predictive markers ensures that the most appropriate treatment regimen is offered.
Data from the Royal College of Physicians’ National Lung Cancer Audit (NLCA) show that pathological confirmation rates in all stages of lung cancer dropped in 2014. They have since shown improvement but still remain below the 2013 rate.
Tumours grow when, instead of repairing or self-destructing, mutated cells continue to multiply. Samples of the cancerous cells can be biopsied and used for pathological analysis to provide detail on the type of mutation. This is known as pathological diagnosis.
Cancer stage refers to how much the cancer has developed by growing and spreading. Stage 1 lung cancer is small and hasn’t spread, while stage 4 has usually spread to the other lung, or other parts of the body such as the liver, bones or brain. Accurate assessment of stage often involves various scans and other tests, such as an endobronchial ultrasound, a technique used to visualise the airway.
The latest report from the NLCA, published in May 2019, reports pathological confirmation rates in people with early stage lung cancer only. This is because some clinicians feel that people who have late stage lung cancer are unlikely to tolerate or benefit from an invasive biopsy. Similarly, NICE recommends that pathological diagnosis should only be performed without unacceptable risk to the person. In 2017, the pathological confirmation rate for people with stage 1 to 2 lung cancer who had a performance status of 0 to 1 was 89% in England.
To enable increased pathological diagnosis rates, the NHS Long Term Plan details plans to increase capacity in diagnostic services by investing new equipment and staff.
Performance status (PS) is a measure of how well a person is able to carry on ordinary daily activities while living with cancer and provides an estimate of what treatments a person may be able to tolerate. Someone whose PS is 0 or 1 can carry out most of their usual daily activities without help, whereas someone with a PS of 4 is usually confined to a bed or chair and needs help with all daily activities.
Multidisciplinary team meetings
Multidisciplinary team meetings are key to the effective diagnosis and staging of lung cancer. Bringing together a breadth of experience and knowledge from a range of healthcare professionals to form a multidisciplinary team allows for rapid decisions around patient assessment and appropriate treatment. Lung cancer multidisciplinary teams will often include a chest physician, radiologist, pathologist, specialist nurse, oncologist, surgeon and members of a palliative care team.
Recent years have seen an increase in the proportion of people with lung cancer that are being discussed at multidisciplinary team meetings
NICE recommends that the care of all people with suspected lung cancer should be discussed at a lung cancer multidisciplinary team meeting. Data from the NLCA show that, in 2017, 87% of people with lung cancer were discussed at an multidisciplinary team meeting. This is an increase from 82% in the 2015 audit.