Clinical and organizational factors in the initial evaluation of patients with lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

Abstract

Background: This guideline is intended to provide an evidence-based approach to the initial evaluation of patients with known or suspected lung cancer. It also includes an assessment of the impact of timeliness of care and multidisciplinary teams on outcome.

Methods: The applicable current medical literature was identified by a computerized search and evaluated using standardized methods. Recommendations were framed using the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. Data sources included MEDLINE and the Cochrane Database of Systematic Reviews.

Results: Initial evaluation should include a thorough history and physical examination; CT imaging; pulmonary function tests; and hemoglobin, electrolyte, liver function, and calcium levels. Additional testing for distant metastases and paraneoplastic syndromes should be determined on the basis of these results. Paraneoplastic syndromes may have an adverse impact on cancer treatment, so they should be controlled rapidly with the goal of proceeding with definitive cancer treatment in a timely manner. Although the relationship between timeliness of care and survival is difficult to quantify, efforts to deliver timely care are reasonable and should be balanced with the need to attend to other dimensions of health-care quality (eg, safety, effectiveness, efficiency, equality, consistency with patient values and preferences). Quality care will require multiple disciplines. Although it is difficult to assess the impact, we suggest that a multidisciplinary team approach to care be used, particularly for patients requiring multimodality therapy.

Conclusions: The initial evaluation of patients with lung cancer should include a thorough history and physical examination, pulmonary function tests, CT imaging, basic laboratory tests, and selective testing for distant metastases and paraneoplastic syndromes.

Figure 1.

[Introduction, Section 2.3] Overview of initial evaluation, diagnosis, staging, and treatment processes. There is significant overlap between cognitive processes. Developing a clinical diagnosis and assessment of the probable stage begins during the initial evaluation. This clinical assessment is subsequently refined on the basis of biopsy specimen findings that are part of formal staging and diagnosis. Similarly, information regarding the patient’s functional status, comorbid conditions, and preferences may have an impact on treatment alternatives, and this in turn may have an impact on the type of diagnostic testing strategies chosen. CXR = chest radiograph.

Figure 2.

[Introduction] Diagnostic algorithm for patients with suspected non-small cell lung cancer.The initial evaluation provides information on comorbidities, functional status, preferences, and probable extent of disease. The results of the initial evaluation determine the optimal site and sequencing of additional diagnostic and staging tests. Staging and diagnosis will be most efficient if the most advanced site of disease is targeted first. *When there is overwhelming imaging evidence of distant metastases, biopsy of the most accessible site is sufficient. DLCO = diffusing capacity of lung for carbon monoxide; EBUS-NA = endobronchial ultrasound-guided needle aspiration.

Figure 3.

[Section 2.0] Range of frequencies of initial symptoms and signs of lung cancer.

Figure 4.

[Section 2.4.1] Features of a standardized evaluation for systemic metastases.

Figure 5.

[Section 3.0] Paraneoplastic syndromes in patients with lung cancer.

Figure 6.

[Section 3.1.4] Food and medications to avoid during urine collection for 5-HIAA measurement.

Figure 7.

[Section 3.2.1] Autoimmune paraneoplastic syndromes associated with lung cancer.

Figure 8.

[Section 4.0] Time to treatment in US studies of timeliness of care in lung cancer.