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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
Top Tips for GPs holding a 2WW Conversation
Macmillan 2WW guidance
Scope:
- assessment, diagnosis and, management of lung cancer in adults, including:
- diagnosis and staging
- surgical treatment, chemotherapy, radiotherapy, endobronchial therapy, radiofrequency ablation (RFA)
- principles of palliative care in lung cancer
Out of scope:
- mesothelioma
- population screening and prevention strategies
- carcinoma in situ
- detailed management of rarer pulmonary cancers, eg carcinoid
- metastatic disease to the lung from another primary site
Definition:
- non-small cell lung cancer (NSCLC) main subtypes:
- squamous cell carcinoma (SCC) [9]:
- arises typically in proximal, lobar, or segmental bronchi
- tends to spread locally, metastasising later than other types
- tumour cells show keratinisation and/or intercellular bridging
- adenocarcinoma [9]:
- tends to be peripherally located
- may be mucinous or non-mucinous
- shows a variety of histological patterns (lepidic, acinar, papillary, micropapillary, solid) that both reflect the degree of differentiation and correlate with some gene mutations
- NSCLC lacking evidence of squamous or adenocarcinomatous differentiation consists of large polygonal cells with vesicular nuclei
- small cell lung cancer (SCLC) [4]:
- originates from neuroendocrine-cell precursors
- characterised by its rapid growth, its high response rates to both chemotherapy and radiotherapy, and development of treatment resistance in patients with metastatic disease
Metastatic disease:
- common sites for lung cancer metastases include [1]:
- brain
- liver
- adrenal glands
- bone
- lymph nodes
- contralateral lung
- pleura
Incidence and prevalence:
- in the UK, lung cancer is now the most common cause of cancer death in both men and women [1]
- accounts for approximately 35,000 deaths per year in England and Wales [1]
- NSCLC accounts for approximately 85% of lung cancer cases [3]
- SCLC accounts for approximately 15% of lung cancer cases [3]
Risk factors:
- cigarette smoking is the primary risk factor, accounting for up to 90% of cases [1]:
- smoking more than 20 cigarettes per day increases the age-adjusted relative risk of lung cancer by 20 times, compared with lifelong non-smoking
- stopping smoking before middle age means that an individual can avoid almost 90% of the risk, although the risk never drops to the pre-smoking level
- passive tobacco smoke [2]
- occupational hazards − exposure to [2]:
- asbestos
- arsenic
- beryllium
- bis-(chloromethyl)-ether
- cadmium
- chromium
- nickel
- polycyclic aromatic hydrocarbons
- vinyl chloride
- other associations:
- air pollution and environmental exposure, eg radon
- poor nutrition
- previous or co-existing lung disease – patients with chronic obstructive pulmonary disease (COPD) have an excess risk (independent of their smoking history) of at least double that of those without COPD, but probably much higher [3]
- therapeutic ionising radiation
- genetic predisposition
- increasing age:
- lung cancer under age 40 years is rare [1]:
- incidence rises sharply with age
- median age at presentation is age 72 years
Prognosis:
- varies depending on stage and type of lung cancer but generally very poor as symptoms usually present late in disease progression [1]
- 1 year survival rate for all lung cancer is 36% for women and 32.5% for men [3]
- 5 year survival rate is 8.8% in women and 7.1% in men [3]
- median survival for SCLC with treatment [2]:
- approximately 14-18 months for limited stage disease
- approximately 9-12 months for extensive stage disease
- 2 year survival rate for SCLC [2]:
- approximately 20-40% for limited disease
- less than 5% for extensive disease
UHB Patient Information Leaflet
NBT Patient Information Leaflet
WAHT Patient Information Leaflet
NSCCG Sign off form 2017
Updated in line with NICE Guideline NG12: Suspected cancer: recognition and referral to coincide with updated BNSSG 2WW Referral forms
Date of publication: 31-Jul-2014
Information on prognostic factors has been provided from:
- [4] Fruh M, De Ruysscher D, Popat S et al. Small-cell lung cancer (SCLC): ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Annals of Oncology 2014; 24: vi99-vi105.
Information covering presentation of lung cancer, diagnostic and staging procedures, adjuvant therapy, second-line treatment, and patients presenting with a normal chest X-ray has been provided from:
- [5] Scottish Intercollegiate Guidelines Network (SIGN). Management of lung cancer. SIGN Publication no. 137. Edinburgh: SIGN; 2014.
- [9] Detterbeck FC, Lewis SZ, Diekemper R et al. Executive Summary: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143: 7S-37S.
Information on management of small cell lung cancer has been provided from:
- [12] National Comprehensive Cancer Network (NCCN). Small cell lung cancer. Version 2. 2014. NCCN clinical practice guidelines in oncology (NCCN guidelines ®). Fort Washington, PA: NCCN; 2014.
Information on preoperative chemotherapy has been provided from:
- [13] NSCLC Meta-Analysis Collaborative Group. Preoperative chemotherapy for non-small cell lung cancer: a systematic review and meta-analysis of individual participant data. Lancet 2014.
Information on patients presenting with spinal pain has been provided from:
- [15] National Institute for Health and Care Excellence (NICE). Metastatic spinal cord compression. Quality Standard 56. London: NICE; 2014.
Afatinib as systemic anticancer treatment for non-small-cell lung cancer has been provided from:
- [16] National Institute for Health and Care Excellence (NICE). Afatinib for treating epidermal growth factor receptor mutation-positive locally advanced or metastatic non-small-cell lung cancer. Technology appraisal 310. London: NICE; 2014.
Pemetrexed as maintenance treatment has been been provided from:
- [17] National Institute for Health and Care Excellence (NICE). Pemetrexed maintenance treatment following induction therapy with pemetrexed and cisplatin for non-squamous non-small-cell lung cancer: Technology appraisal 309. London: NICE; 2014.
Follow-up information has been provided from:
- [21] Vansteenkiste J, De RD, Eberhardt WE et al. Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013; 24 Suppl 6: vi89-vi98.
Information on the use of PET-CT has been provided from:
- [23] Royal College of Physicians (RCP), Royal College of Radiologists (RCR). Evidence-based indications for the use of PET-CT in the UK. London: RCP, RCR; 2013.
Information on adjuvant chemotherapy has been added in line with:
- [31] Gilligan D, Nicolson M, Smith I et al. Preoperative chemotherapy in patients with resectable non-small cell lung cancer: results of the MRC LU22/NVALT 2/EORTC 08012 multicentre randomised trial and update of systematic review. Lancet 2007; 369: 1929-37.
Expert opinion has been added to this care map in line with:
- [32] Contributors representing the Royal College of Physicians (RCP); 2014.
Symptoms and signs of lung cancer include:
- frequent:
- cough [1,5]
- weight loss [2,5]
- dyspnoea [1,2,5]
- chest pain (or shoulder pain) [2,5]
- haemoptysis (blood-stained sputum; present in 20%) [1,2]
- lethargy/tiredness [2,5]
- moderately frequent:
- bone pain [5]
- digital clubbing [1]
- fever [7]
- weakness [7]
- anxiety and depression [5]
- infrequent:
- pain radiating down arm (Pancoast tumour) [9]
- superior vena cava obstruction [9]
- wheezing and stridor [1]
- symptoms from metastases, eg to [1]:
- brain
- bone
- liver
- lymph nodes
NB: Patients may be diagnosed after their tumour is picked up incidentally on chest X-ray or other imaging tests, and may not present with any classic symptoms of lung cancer [5,9
Macmillan Cancer Support Rapid Referral Guidelines
Ask about:
- symptoms [7]:
- onset
- duration
- frequency
- any changes to existing symptoms in patients with underlying respiratory problems
- change in appetite or weight loss [2,5]
- history of smoking [1,5]
- history of respiratory disease, eg chronic obstructive pulmonary disease (COPD) [5]
- contact with carcinogenic chemicals [2]
- occupational exposure to asbestos [2]
- family history of cancer [7]
- past medical history [7]
Examination:
- general appearance, eg:
- weight loss [2,5]
- shortness of breath at rest [1,5]
- heart rate
- blood pressure (BP)
- check for digital clubbing [1]
- check for enlarged cervical and supraclavicular lymph nodes [7]
- evidence of superior vena cava obstruction [7]
- respiratory system [7]:
- respiratory rate
- equal chest expansion
- percussion of chest wall
- points of bony tenderness
- auscultation [1]:
- stridor
- wheeze
- crepitations
- abdominal palpation including inguinal lymph nodes [7]
Differentials of symptoms (non-acute presentation) − these may be present in addition to lung cancer [6]:
- chronic obstructive pulmonary disease (COPD) [9]
- pneumonia [6]
- tuberculosis [6]
- pleural effusion (all causes) [9]
- bronchiectasis [6]
- inhaled foreign body [6]
- diffuse parenchymal lung diseases [6]
- carcinoid tumour [6]
- mesothelioma [6]
- secondary tumours [6]
Explain smoking cessation may improve outcomes [1]:
- as soon as diagnosis of lung cancer is suspected, advise smoking cessation and explain why this is important
- offer nicotine replacement therapy and other appropriate therapies to aid cessation
- do not postpone surgery for lung cancer to allow patient to stop smoking
- see 'Smoking cessation' guidelines
National Institute for Health and Care Excellence (NICE) guidelines suggest considering immediate (same day) referral to chest physician within lung cancer multidisciplinary team (MDT), without waiting for chest X-ray, if either of the following are present [1,7]:
- signs of superior vena caval obstruction :
- swelling of face or neck
- fixed elevation of jugular venous pressure
- stridor
Consider immediate referral to an Emergency Department if the patient has [26]:
- massive haemoptysis
- new neurological signs suggestive of brain metastases or cord compression
Arrange emergency admission
If high clinical suspicion, annotate x-ray request to report urgently. All x-ray results can be viewed on ICE.
Arrange an urgent chest X-ray for patients with:
- any presentation of haemoptysis [1,5,7]
- any of the following symptoms or signs that are unexplained or persistent [7]:
- cough
- dyspnoea
- chest or shoulder pain
- hoarseness
- chest signs on examination
- digital clubbing
- cervical or supraclavicular lymphadenopathy
- weight loss
- features suggestive of metastatic lung cancer, eg to:
- unexplained changes in existing symptoms in patients with underlying respiratory problems
Consider urgent chest X-ray or referral sooner for patients in the following groups [7]:
- people with smoking-related chronic obstructive pulmonary disease (COPD)
- people who have been exposed to asbestos
- people with a previous history of cancer, especially head and neck
Offer urgent referral (to be seen within 2 weeks) to chest physician within lung cancer multidisciplinary team (MDT) while waiting for chest X-ray result if there is [1,7]:
- unexplained haemoptysis in age 40 years or older
Please arrange a chest x-ray to take place in next 48 hours
- have chest X-ray findings that suggest lung cancer or mesothelioma (location of x-ray )
Chest X-ray should be no more than 3 weeks old
- have a normal chest X-ray but with a high index of suspicion
(Up to 25% of chest X-rays can be falsely negative in lung cancer so if the clinical suspicion is high or there is clinical lymphadenopathy or clubbing, refer via two week wait to fast track lung cancer service.)
NB: National Institute for Health and Care Excellence (NICE) guidelines suggest considering immediate (same day) referral to chest physician within multidisciplinary team (MDT), without waiting for chest X-ray, if either superior vena cava obstruction or stridor are present [1,7].
Local administrative information
Clevedon – 01275 342571
GP can request via ICE (NBT)
Walk-in service available
X - Ray - 09:00 - 13:00 & 14:00 - 16:00 week days only
Weston General Hospital – Direct Access Patients - 01934 636363 ext 3340
The department is responsible for all plain film work (normal x-rays) in the hospital. It is located on the ground floor of Weston General Hospital. Plain films include chest X-Rays. Patients who need a chest x-ray are referred electronically by their GP, are given a request form to present at the x-ray department and can attend any weekday between 11am and 3pm.
Bristol Royal Infirmary - Direct Access Patients - Chest X-rays - 0117 342 2639
Plain Films: Appointments are not required for general non-invasive studies, e.g. lumbar spine and chest x-rays. Patients will be examined on a first come first seen basis. Monday to Friday between 9am and 4pm
Southmead - Direct Access Patients - 0300 300 0089
Chest x-rays should be requested on ICE. Patients should go to the Imaging Department, Gate 18, Level 1, Brunel building, Southmead Hospital, between 8.30am and 5pm Monday – Friday
Referral for high suspicion of lung cancer:
- National Institute for Health and Care Excellence (NICE) guidelines recommend that people with a normal chest X-ray but high suspicion of lung cancer should be referred urgently (within 2 weeks) to chest physician within lung cancer multidisciplinary team (MDT) for clinical examination, history, and blood test [1]
- Scottish Intercollegiate Guidelines Network (SIGN) recommends that people with normal chest X-ray but unexplained clinical findings should be referred via 2WW to respiratory medicine [5]
Radiographically, lung cancer usually presents as [1]:
- pleural effusion
- slowly resolving or recurrent consolidation
- solitary pulmonary nodule or pulmonary mass
- pulmonary or lobar collapse
- mediastinal lymphadenopathy
People with X-ray result suggestive of lung cancer should be referred to chest physician within lung cancer multidisciplinary team (MDT) to be seen within 2 weeks [1,7].
Patients with lung cancer can present with a normal chest X-ray [5,9].
If the chest X-ray is normal but there is a high suspicion of lung cancer, patients should be offered a two week wait referral [7].
Referral for high suspicion of lung cancer:
- National Institute for Health and Care Excellence (NICE) guidelines recommend that people with a normal chest X-ray but high suspicion of lung cancer should be referred urgently (within 2 weeks) to chest physician within lung cancer multidisciplinary team (MDT) for clinical examination, history, and blood test [1]
- Scottish Intercollegiate Guidelines Network (SIGN) recommends that people with normal chest X-ray but unexplained clinical findings should be referred via 2WW to respiratory medicine [5]
Radiographically, lung cancer usually presents as [1]:
- pleural effusion
- slowly resolving or recurrent consolidation
- solitary pulmonary nodule or pulmonary mass
- pulmonary or lobar collapse
- mediastinal lymphadenopathy
People with X-ray result suggestive of lung cancer should be referred to chest physician within lung cancer multidisciplinary team (MDT) to be seen within 2 weeks [1,7].
If there is no lung pathology and low suspicion of lung cancer, observe patient and manage symptoms [1].
No further information has been provided for this node.
Refer for imaging
The UHB xray request form is available as an EMIS template
Criteria
Patients must meet one or more of the following criteria:
Urgent admission - see Red Flag Criteria
- Signs of superior vena cava obstruction
- Stridor
2ww Referral
- Unexplained haemoptysis (in 40 years or older)
- Chest x-ray suggestive of lung cancer (including pleural effusion and slowly resolving consolidation)
- Normal chest x-ray with high suspicion of lung cancer
- History of asbestos exposure and recent onset of chest pain, shortness of breath or unexplained systemic symptoms where a chest x-ray indicates pleural effusion, pleural mass or any suspicious lung pathology
Please ensure the following recent blood results are available (less than 8 weeks old)
- FBC
- eGFR
- clotting
- C&E
- LFT
- bone profile
Lung Function if available
Anticoagulation
- Please provide details and latest INR
2WW Lung Services are provided at Weston (WAHT), BRI (UHB) and Southmead (NBT)
2WW referral forms are available as EMIS templates
Bone & Soft Tissue - 2WW
