4 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.

4.1 Selection of patients with NSCLC for treatment with curative intent

Further studies should be performed into factors that predict successful outcome of treatment with curative intent. Studies should include fitness parameters and functional imaging.

Why this is important

Despite much research into factors that predict a successful outcome after treatment with curative intent it is still not clear how these relate to the patient with borderline fitness. To ensure that fitness assessment is robust, consistent and meaningful, the place of exercise testing, lung function testing and functional imaging should be clearly defined by appropriately designed trials.

4.2 Effectiveness of surgery with or without multimodality treatment in N2 disease

Patients with non-bulky single zone N2 disease should be considered for trials of surgery with or without multimodality treatment. Outcomes should include mortality and 5-year survival.

Why this is important

A number of randomised controlled trials have been evaluated in this guideline that have shown that surgery, as part of multimodality treatment, does not worsen prognosis in patients with N2 disease. However, these studies did not distinguish between those patients who might intuitively benefit from surgery (a limited number of nodes involved and/or a single zone affected) and those with more extensive disease and potentially less favourable biology (many nodes involved and/or multiple zones affected). Further trials are needed to establish the role of surgeryin this heterogeneous group.

4.3 Pulmonary rehabilitation, optimisation of drug treatment and enhanced recovery programmes

Research should be undertaken into the benefits of pulmonary rehabilitation, optimisation of drug treatment and enhanced recovery programmes before and after surgery. Outcomes should include mortality, survival, pulmonary complications, pulmonary function and quality of life (including assessment by EQ-5D).

Why this is important

There is some evidence that pulmonary rehabilitation, optimisation of drug treatment and enhanced recovery programmes are effective in patients undergoing surgery for some conditions but none for patients undergoing surgery for lung cancer. Fitness for surgery and the ability of the patient to recover following surgery are key factors in the success of this treatment for lung cancer. The effectiveness of interventions to improve these factors should be evaluated.

4.4 New regimens for radiotherapy with curative intent

Research should be considered into dose escalation in radiotherapy with curative intent, including stereotactic body irradiation (SBRT). Outcomes should include mortality, pulmonary complications, pulmonary function and validated quality of life measures (including assessment by EQ-5D).

Why this is important

There have been considerable technological advances in radiotherapy equipment that has allowed radiotherapy to be more accurately delivered to the tumour and hence less damaging to normal tissues. This has allowed new regimens to be developed, including SBRT, which have not been evaluated adequately for their efficacy and toxicity.

4.5 Imaging modalities for monitoring response and recurrent disease

Randomised controlled trials should be conducted to examine the value of imaging modalities and other interventions in the monitoring of response and recurrent disease.

Why this is important

Patients with lung cancer have high recurrence rates even when treated with curative intent. It is not known whether imaging modalities and other interventions in the follow-up period can improve outcomes by detecting recurrence or relapse earlier. Therefore no firm recommendations can be made about their scheduling or use. This question should be addressed through properly designed clinical trials.

  • National Institute for Health and Care Excellence (NICE)