Lung Cancer Clinical Practice Guidelines (2018)

National Comprehensive Cancer Network

Reviewed and summarized by Medscape editors

May 11, 2018

The clinical practice guidelines on lung cancer were released by the NCCN in April 2018.[1]

It is recommended that institutions performing lung cancer screening use a multidisciplinary approach that includes the specialties of thoracic radiology, pulmonary medicine, and thoracic surgery.

Lung cancer screening is appropriate to consider for high-risk patients who are potential candidates for definitive treatment. Chest x-ray is not recommended for lung cancer screening.

All current smokers should be advised to quit smoking, and former smokers should be advised to remain abstinent from smoking. Lung cancer screening should not be considered a substitute for smoking cessation. Smoking history should document both extent of exposure in pack-years and the amount of time since smoking cessation in former smokers.

There is increased risk of developing new primary lung cancer among survivors of lung cancer, lymphomas, cancers of the head and neck, or smoking-related cancers.

Individuals exposed to second-hand smoke have a highly variable exposure to the carcinogens, with varying evidence for increased risk after this variable exposure. Therefore, second-hand smoke is not independently considered a risk factor for lung cancer screening.

Although randomized trial evidence supports screening to age 74 years, there is uncertainty about the upper age limit to initiate or continue screening. One can consider screening beyond age 74 years as long as patient functional status and comorbidity allow consideration for curative intent therapy.

All screening and follow-up chest CT scans should be performed at low dose (100–120 kVp and 40–60 mAs or less), unless evaluating mediastinal abnormalities or lymph nodes, where standard-dose CT with IV contrast might be appropriate. There should be a systematic process for appropriate follow-up.

PET has a low sensitivity for nodules with less than 8 mm of solid component and for small nodules near the diaphragm. PET/CT is only one consideration of multiple criteria for determining whether a nodule has a high risk of being lung cancer. In areas endemic for fungal disease, the false-positive rate for PET/CT is higher.

If biopsy is non-diagnostic and a strong suspicion for cancer persists, suggest repeat biopsy or surgical excision or short-interval follow-up (3 months).


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