Lung cancer: diagnosis and management

Immunotherapy has been shown to be effective in a variety of NSCLC indications but there is currently no evidence on whether it is clinically or cost effective for people with stage 3a N2 NSCLC following surgery. The committee made a recommendation for research on immunotherapy after multimodality treatment to address this.

There are not many randomised controlled trials comparing SABR with surgery (lobectomy or sublobar resection). SABR is non-invasive, so if it is as effective as surgery then it may be a preferable option for many people with lung cancer. There are also various factors that may make SABR less costly than surgery. For example, it is usually delivered as outpatient treatment. There might also be subgroups for whom different forms of surgery or SABR might be the most cost-effective options. The committee made a recommendation for research on SABR compared with surgery to investigate these uncertainties.

The 2018 review only examined the clinical and cost effectiveness of imaging after the treatment plan has been decided, but the committee noted that it could be more efficient to conduct CT brain imaging alongside initial staging CT. With this in mind, the committee made a recommendation for research on routine brain imaging with CT at initial diagnosis and/or staging.

Prophylactic cranial irradiation

The evidence showed that prophylactic cranial irradiation improves survival versus best supportive care.

Prophylactic cranial irradiation can adversely affect quality of life, and the survival benefits are limited. There is also some evidence from a study outside the UK that routine MRI follow-up may be more cost effective. The committee made a recommendation for research on prophylactic cranial irradiation compared with routine MRI follow-up in extensive-stage SCLC, to provide evidence more relevant to the UK and to see if MRI could identify people who need whole-brain radiotherapy and so reduce the number of people having unnecessary treatment.