Chest
Volume 132, Issue 3, Supplement, September 2007, Pages 368S-403S
Journal home page for Chest

DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)
Palliative Care in Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)

https://doi.org/10.1378/chest.07-1391Get rights and content

Goals/objectives

To review the scientific evidence on symptoms and specific complications that are associated with lung cancer, and the methods available to palliate those symptoms and complications.

Methods

MEDLINE literature review (through March 2006) for all studies published in the English language, including case series and case reports, since 1966 using the following medical subject heading terms: bone metastases; brain metastases; cough; dyspnea; electrocautery; hemoptysis; interventional bronchoscopy; laser; pain management; pleural effusions; spinal cord metastases; superior vena cava syndrome; and tracheoesophageal fistula.

Results

Pulmonary symptoms that may require palliation in patients who have lung cancer include those caused by the primary cancer itself (dyspnea, wheezing, cough, hemoptysis, chest pain), or locoregional metastases within the thorax (superior vena cava syndrome, tracheoesophageal fistula, pleural effusions, ribs, and pleura). Respiratory symptoms can also result from complications of lung cancer treatment or from comorbid conditions. Constitutional symptoms are common and require attention and care. Symptoms referable to distant extrathoracic metastases to bone, brain, spinal cord, and liver pose additional problems that require a specific response for optimal symptom control. There are excellent scientific data regarding the management of many of these issues, with lesser evidence from case series or expert opinion on other aspects of providing palliative care for lung cancer patients.

Conclusions

Palliation of symptoms and complications in lung cancer patients is possible, and physicians who provide such care must be knowledgeable about these issues.

Section snippets

Methods and Materials

The key words for various palliative care topics, as listed in above-mentioned “Key words” section, were searched using Ovid MEDLINE and PubMed from 1966 through March 1, 2006. Randomized controlled trials (RCTs) were especially sought for all such topics; where this type of study was available, it is clearly identified as such in the appropriate section of this chapter. For many of the topics, evidence is of substantially less quality, and it typically consists of case series of varying size.

Pain Control

Studies reveal that adults with lung cancer have more symptoms than patients with other types of cancer.28 Pain is a common symptom in lung cancer patients, yet inadequate pain management is prevalent, harmful to patients, and costly.29 A comprehensive document for the management of cancer pain was developed and published in 1994 as part of a response to Public Law 101–239 (the Omnibus Reconciliation Act of 1989), under the aegis of the Agency for Health Care Policy and Research. The name

Recommendations

1. All lung cancer patients and their families must be reassured that pain can be relieved safely and effectively. All patients should be questioned regularly about their pain, using the patient's self-report of pain and a simple rating scale as the primary source of assessment. Grade of recommendation, 1A

2. For all patients, individualize medications that are used to control pain. Administer medications regularly and treat pain appropriately. Document the effectiveness of pain management at

Recommendations

12. For all lung cancer patients who complain of dyspnea, it is recommended that they be evaluated for potentially correctable causes, such as localized obstruction of a major airway, a large pleural effusion, pulmonary emboli, or an exacerbation of coexisting COPD or congestive heart failure. If one of these problems is identified, treatment with appropriate methods is recommended. Grade of recommendation, 1C

13. For all lung cancer patients whose dyspnea does not have a treatable cause,

Recommendations

15. For all lung cancer patients who have troublesome cough, it is recommended that they be evaluated for treatable causes. Grade of recommendation, 1B

16. For all lung cancer patients who have troublesome cough without a treatable cause, it is recommended that opioids be used to suppress the cough. Grade of recommendation, 1B

Recommendations

17. For patients with lung cancer who have pain due to bone metastases, external radiation therapy is recommended for pain relief. A single fraction of 8 Gy is as effective as higher fractionated doses of external radiation therapy for immediate relief of pain. Grade of recommendation, 1A

18. For patients with lung cancer who have pain due to bone metastases, higher fractionated doses of radiation therapy provide a longer duration of pain relief, less frequent need for retreatment, and fewer

Recommendations

22. In patients with lung cancer who have symptomatic brain metastases, dexamethasone at 16 mg/d is recommended during the course of definitive therapy with a rapid taper and discontinuation within 6 weeks of completion of definitive therapy (either surgery or radiation therapy). Grade of recommendation, 1B

23. Patients with NSCLC and an isolated solitary brain metastasis should be considered for a curative resection of the lung primary tumor as long as a careful search for other distant

Recommendations

25. For cancer patients with lung cancer who have the new onset of back pain, sagittal T1-weighted MRI of the entire spine is recommended for diagnostic purposes. Other diagnostic studies such as plain radiographs, bone scans, or CT myelograms are not recommended. Grade of recommendation, 1C

26. For patients with lung cancer and epidural spinal cord metastases who are not paretic and ambulatory, prompt treatment with high-dose dexamethasone and radiotherapy is recommended. Grade of

Recommendation

28. For all lung cancer patients with large-volume hemoptysis, bronchoscopy is recommended to identify the source of bleeding, followed by endobronchial management options such as APC, Nd-YAG laser, and electrocautery. Grade of recommendation, 1C

Recommendations

29. In lung cancer patients with symptomatic malignant pleural effusions, thoracentesis is recommended as the first drainage procedure for symptom relief. Grade of recommendation, 1C

30. In lung cancer patients with symptomatic pleural effusions that recur after thoracentesis, chest tube drainage and pleurodesis are recommended. Grade of recommendation, 1B

Recommendations

31. In patients with SVC obstruction from suspected lung cancer, definitive diagnosis by histologic or cytologic methods is recommended before treatment is started. Grade of recommendation, 1C

32. In patients with symptomatic SVC obstruction due to SCLC, chemotherapy is recommended. Grade of recommendation, 1C

33. In patients with symptomatic SVC obstruction due to NSCLC, stent insertion and/or radiation therapy are recommended. Stents are also recommended for SCLC or NSCLC symptomatic patients

Recommendation

35. For patients with malignant TEF or bronchoesophageal fistula, stenting of esophagus, airway, or both should be considered for symptomatic relief. Attempts at curative resection or esophageal bypass of the involved airway and/or the esophagus are not recommended. Grade of recommendation, 1C

Recommendation

36. It is recommended that all patients with lung cancer be evaluated for the presence of depression and, if present, treated appropriately. Grade of recommendation, 1C

Conclusion

The majority of patients with lung cancer will have one or more symptoms or complications from metastatic disease. These symptoms will severely alter the patient's quality of life. It is important for clinicians who care for lung cancer patients to be familiar with these many different symptoms and complications of the disease, and to utilize the many available methods that are designed to palliate these problems and improve the patient's life quality.

SUMMARY OF RECOMMENDATIONS

  • 1

    All lung cancer

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