Elsevier

Clinical Oncology

Volume 28, Issue 11, November 2016, Pages 682-694
Clinical Oncology

Overview
Assessment and Optimisation of Lung Cancer Patients for Treatment with Curative Intent

https://doi.org/10.1016/j.clon.2016.08.002Get rights and content

Abstract

Over the past decade the field of lung cancer management has seen many developments. Coupled with an ageing population and increasing rates of comorbid illness, the work-up for treatments with curative intent has become more complex and detailed. As well as improvements in imaging and staging techniques, developments in both surgery and radiotherapy may now allow patients who would previously have been considered unfit or not appropriate for treatment with curative intent to undergo radical therapies. This overview will highlight published studies relating to investigation and staging techniques, together with assessments of fitness, with the aim of helping clinicians to determine the most appropriate treatments for each patient. We also highlight areas where further research may be required.

Section snippets

Statement of Search Strategies Used and Sources of Information

The terms ‘surgical staging’, ‘pulmonary function testing’, ‘mediastinal staging’, ‘performance status’, ‘cardiovascular risk score’, ‘fitness for surgery’, ‘thoracoscore’, ‘smoking cessation’ and ‘pulmonary rehabilitation’ were used to search PubMed and all relevant studies relating to lung cancer were included in the preparation of this overview.

Diagnostic and Staging Investigations – Imaging

Accurate staging is essential for identifying the best treatment for each patient, leading to optimal treatment outcomes. Over the last 15 years there has been a significant change in the approach to lung cancer staging, with improvements in cross-sectional and functional imaging and a move away from surgical staging techniques towards minimally invasive approaches such as endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS).

Diagnostic and Staging Investigations – Pathological Confirmation

Accurate pathological diagnosis is key to determining the optimal treatment for patients with lung cancer. Current national clinical guidelines state that lung cancer should be histologically confirmed whenever practical and make clear recommendations around the sequence of investigations that should be used to diagnose and stage lung cancer [16]. Patients being considered for treatment with curative intent should have computed tomography and PET-CT carried out before biopsies are undertaken.

Age

Although age can be associated with an increased number of significant comorbidities, age alone should not exclude a patient from being considered for surgical treatment [28], [29], [30]. About 30–35% of candidates for surgical resection of lung cancer are aged >70 years [31]. Several guidelines focussing on decision-making in elderly patients with lung cancer agree that assessments of cardiovascular and pulmonary fitness for surgery should be carried out independent of age [16], [30], [31],

Assessment for Curative, Non-surgical Treatments

Although surgery remains the gold standard treatment for patients with early stage lung cancer, those with a good performance status, deemed to have non-operable disease or who decline surgery should still be considered for curative treatments with radiotherapy or chemoradiotherapy. Generally patients with localised disease who are performance status 0-1, without significant comorbidities are suitable. Some performance status 2 patients may also be suitable, but careful selection and

Smoking Cessation

Smoking cessation is always recommended in patients with lung malignancy and most patients presenting with lung cancer will be either current smokers or ex-smokers. Current guidelines recommend that smoking cessation be advocated in patients being considered for surgical resection of lung cancer [16], [31], [32]. There is also increasing evidence that smoking can be detrimental to the efficacy of systemic chemotherapy agents used to treat lung cancer, by inducing enzymes that metabolise these

Conclusion

With an aging population and increasing disease complexity, the work-up, staging and physiological assessments of patients with lung cancer is becoming increasingly challenging. The patient being considered for treatment with curative intent is required to undergo multiple investigations to establish their suitability for treatments. Lung cancer management requires the integration of a well-functioning multidisciplinary team in order to achieve optimal results. Management planning should be

Acknowledgements

Robert Rintoul is part funded by the National Institute for Health Research Cambridge Biomedical Research Centre and the Cambridge Cancer Centre.

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    Authors contributed equally.

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