Lung cancer: diagnosis and management

Background to the review

The updated NICE guideline on lung cancer published on 28 March 2019. During consultation on the draft guideline, NHS England's Clinic Expert Group for Lung Cancer commented that recommendation 1.5.8 should reflect the use of indwelling pleural catheters (IPCs). The guideline committee were aware that this area was out of scope for the update, however in their expert opinion felt that the guideline recommendation was out of date with current practice. This issue is examined in this exceptional review.

New evidence

We found 10 new studies in a focused search for systematic reviews and randomised controlled trials on the use of IPC in patients with malignant pleural effusion, published between 1 January 2004 and 28 February 2019. To identify all studies of relevance to this review, the evidence searches included patients with malignant pleural effusion irrespective of cancer site.

Several studies comparing IPC and chemical/talc pleurodesis found no significant differences in outcomes including success rate and improvement of dyspnoea. One identified Cochrane review indicated that whilst IPC patients had improved breathlessness, pleurodesis failure rate was higher in IPC compared with talc slurry pleurodesis patients. There was mixed evidence concerning adverse event rate with IPC use, however several studies noted that IPC may be associated with a shorter length of hospital stay and fewer repeat pleural interventions. Further evidence synthesis is also needed to understand the cost implications associated with IPC use.

Following consideration of the new evidence identified, as well as topic expert feedback, it is recommended the guideline is not updated at this time. However, NICE has commissioned an update of a Cochrane systematic review which examined interventions for the management of malignant pleural effusions. The updated results (due early 2020) may clarify the effectiveness of both IPC and other newer management strategies and help NICE decide whether an update of the guideline is needed.

For further details and a summary of all evidence identified in surveillance, see appendix A.

Guideline development

NICE initially produced guidance on the diagnosis and treatment of lung cancer in February 2005 which was substantially updated and replaced in 2011 and has since been partially updated in March 2019. However pleural interventions were not included in either update, and so the recommendations below on pleural effusion date back to development of the original guideline in February 2005.

The current NICE guideline recommends that pleural aspiration or drainage should be performed in an attempt to relieve the symptoms of a pleural effusion (recommendation 1.5.7) and patients who benefit symptomatically from aspiration or drainage of fluid should be offered talc pleurodesis for longer-term benefit (recommendation 1.5.8). An evidence review and economic analysis informed the development of these recommendations; 1 study was identified which indicated that outpatient IPC could be cost-saving compared with inpatient chest tube and sclerosis. However, the study was not based on the UK health system and measured hospital charges, which do not reflect the true costs. As such, no specific recommendations on the use of IPC in managing malignant pleural effusion were developed.

Previous surveillance

The NICE guideline on lung cancer has undergone 1 previous surveillance review in March 2016 resulting in the partial update which published on 28 March 2019. No new evidence was identified on other palliative treatments in the 2016 surveillance review of the guideline.

Views of topic experts

We engaged with topic experts who were recruited to the NICE Centre for Guidelines Expert Advisers. We received feedback from 4 topic experts, who supported including IPC as part of the palliation pathway.

Topic expert feedback indicated that IPC is widely used in the management of malignant pleural effusions. Several experts suggested that significant work in this area influencing practice has been published, however the cost-effectiveness of IPC is uncertain.

Experts commented that the clinical implications of recommending IPC in this small population would not be extensive but may provide substantial benefit for patients. One expert commented that the management of malignant pleural effusions "tend to be driven by local expertise and availability rather than evidence based". This expert suggested that including IPC within the NICE guideline recommendations may have an impact on "future service provision and the potential for patient benefit".

Whilst we acknowledge that IPC is being used in clinical practice, at present there is insufficient consistent evidence to impact the recommendations on pleural effusion. However, we will keep abreast of research in this area and assess any implications on the NICE guideline.

Other clinical areas

As an update of the guideline has just been published, this exceptional surveillance review was limited to addressing the use of IPC and did not search for new evidence relating to other clinical areas in the guideline.

Equalities

No equalities issues were identified during the surveillance process.

Overall decision

See how we made the decision for further information.