STEP 4: Treatment

Step 4 describes the optimal treatments for lung cancer, the training and experience required of the treating clinicians and the health service characteristics required for optimal cancer care.

All health services must have clinical governance systems that meet the following integral requirements:

  • identifying safety and quality measures
  • monitoring and reporting on performance and outcomes
  • identifying areas for improvement in safety and quality (ACSQHC 2020).

Step 4 outlines the treatment options for lung cancer. For detailed clinical information on treatment options refer to these resources:

The intent of treatment can be defined as one of the following:

  • curative
  • anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
  • symptom palliation.

The treatment intent should be established in a multidisciplinary setting, documented in the patient’s medical record and conveyed to the patient and carer as appropriate.

The potential benefits need to be balanced against the morbidity and risks of treatment.

The lead clinician should discuss the advantages and disadvantages of each treatment and associated potential side effects with the patient and their carer or family before treatment consent is obtained and begins so the patient can make an informed decision. Supportive care services should also be considered during this decision-making process. Patients should be asked about their use of (current or intended) complementary therapies (see Appendix D).

Timeframes for starting treatment should be informed by evidence-based guidelines where they exist. The treatment team should recognise that shorter timeframes for appropriate consultations and treatment can promote a better experience for patients.

Initiate advance care planning discussions with patients before treatment begins (this could include appointing a substitute decision-maker and completing an advance care directive). Formally involving a palliative care team/service may benefit any patient, so it is important to know and respect each person’s preference (AHMAC 2011).

A number of patients may benefit from surgery:

  • those with early-stage NSCLC who are fit for the required surgery
  • those who require surgical diagnosis or palliation.

Timeframe for starting treatment

Surgery should occur within six weeks of the initial specialist referral.

Training and experience required of the surgeon

Fellow of the Royal Australian College of Surgeons or equivalent, with adequate training and experience that enables institutional credentialing and agreed scope of practice in thoracic surgical oncology.

Documented evidence of the surgeon’s training and experience, including their specific (sub-specialty) experience with lung cancer and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having surgery, health services should have these features:

  • critical care support
  • 24-hour medical staff availability
  • 24-hour operating room access and intensive care unit
  • diagnostic imaging
  • pathology
  • nuclear medicine imaging

Patients with NSCLC or small-cell lung cancer (SCLC) may benefit from radiation therapy as outlined below.

Curative intent radiation therapy may be of benefit to patients who:

  • have early-stage (I-II) NSCLC and are unsuitable or unwilling to have surgery
  • have locally advanced (III) NSCLC that is inoperable
  • have limited-stage (I-III) SCLC and:
    • are having combined modality treatment with chemotherapy
    • may benefit from prophylactic cranial irradiation.

Radiation therapy modalities include stereotactic radiation therapy (eVIQ 2019a).

Palliative intent radiation therapy may benefit all patients with NSCLC or SCLC for palliation of the chest and extrathoracic symptoms.

Timeframe for starting treatment

Radiation therapy should begin within six weeks of the initial specialist referral.

Training and experience required of the appropriate specialists

Fellowship of the Royal Australian and New Zealand College of Radiologists or equivalent, with adequate training and experience, institutional credentialing and agreed scope of practice in lung cancer (ACSQHC 2015).

The training and experience of the radiation oncologist should be documented.

Health service unit characteristics

To provide safe and quality care for patients having radiation treatment, health services should have these features:

  • linear accelerator (LINAC) capable of image-guided radiation therapy (IGRT)
  • dedicated CT planning
  • access to MRI and PET imaging
  • automatic record-verify of all radiation treatments delivered
  • a treatment planning system
  • trained medical physicists, radiation therapists and nurses with radiation therapy experience
  • coordination for combined therapy with systemic therapy, especially where facilities are not co-located
  • participation in Australian Clinical Dosimetry Service audits
  • an incident management system linked with a quality management system

Local ablative therapies such as microwave and radiofrequency ablation may provide alternative curative or palliative treatments in select patients:

  • with localised NSCLC who are unsuitable for surgery or radiotherapy
  • with oligometastatic NSCLC who are unsuitable for surgery or radiotherapy
  • undergoing multi-modality treatment in combination with radiotherapy, chemotherapy or immunotherapy.

Timeframe for starting treatment

Local ablative therapies should begin within six weeks of the initial specialist referral. Where appropriate, treatment should be coordinated with other treatments.

Training and experience required of the appropriate specialists

  • An interventional radiologist (FRANZCR or equivalent) with adequate training and experience, and with institutional credentialing and agreed scope of practice in lung cancer.
  • Ablation should only be performed by credentialed practitioners.
  • European Board of Interventional Radiology Certification (EBIR) certification, or equivalent standard, is recommended.

Documented evidence of the radiologist’s training and experience, including their specific experience with lung ablation and procedures to be undertaken, should be available.

Oligometastatic disease refers to a clinical situation where there are a limited number of metastatic tumours, which could potentially be managed with curative intent. Appropriate cases should be referred to centres with expertise in this area, for consideration of appropriate treatment options outlined above.

A number of patients may benefit from systemic therapy:

  • those with advanced disease and good performance status
  • NSCLC patients having neoadjuvant or adjuvant therapy in conjunction with complete resection of locoregional disease
  • patients with inoperable localised NSCLC who are suitable for combined modality definitive chemoradiation
  • patients with SCLC, as these are highly chemo-sensitive.

Emerging scenarios may include neoadjuvant treatments with the newer agents.

Timeframes for starting treatment

Systemic therapy should begin within six weeks of the initial specialist referral.

Training and experience required of the appropriate specialists

Medical oncologists must have training and experience of this standard:

  • Fellow of the Royal Australian College of Physicians (or equivalent)
  • adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Cancer nurses should have accredited training in these areas:

  • anti-cancer treatment administration
  • specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
  • the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

  • adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In a setting where no medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having systemic therapy, health services should have these features:

  • a clearly defined path to emergency care and advice after hours
  • access to diagnostic pathology including basic haematology and biochemistry, and imaging
  • cytotoxic drugs prepared in a pharmacy with appropriate facilities
  • occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019b)
  • guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
  • coordination for combined therapy with radiation therapy, especially where facilities are not co-located
  • appropriate molecular pathology access

Several emerging therapies are being investigated for both NSCLC and SCLC. Therapies that show promise for treating NSCLC include targeted therapies and immunotherapies, while chemotherapies, immunotherapies and targeted therapies also show promise for treating SCLC (Yang et al. 2019; Zhang et al. 2019).

The key principle for precision medicine is prompt and clinically oriented communication and coordination with an accredited laboratory and pathologist. Tissue is integral for emerging therapies and it should be treated carefully to instigate appropriate histopathological or molecular diagnostic tests.

Current and emerging therapies for some subtypes of lung cancer rely on cancer biomarkers. Procedural investigations should ensure adequate samples are obtained for molecular biomarkers where possible. Pathologists should perform minimal ancillary investigations to ensure adequate tissue remains for biomarker testing. Biomarker testing should use the most efficient methodologies and be performed by appropriately accredited laboratories and pathologists.

There is an increasing use of molecular tumour boards to discuss and identify uncommon molecular results for emerging or available precision therapies.

Timeframes for commencing treatment

Initial histopathology/cytology results should be available within three days of sample collection for a diagnosis of cancer, and the turnaround time should be two weeks or less for common molecular biomarker testing.

Early referral to palliative care can improve the quality of life for people with cancer and in some cases may be associated with survival benefits (Haines 2011; Temel at el. 2010; Zimmermann et al. 2014). This is particularly true for cancers with poor prognosis.

The lead clinician should ensure patients receive timely and appropriate referral to palliative care services. Referral should be based on need rather than prognosis. Emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers.

The ‘Dying to Talk’ resource may help health professionals when initiating discussions with patients about future care needs (see ‘More information’). Ensure that carers and families receive information, support and guidance about their role in palliative care (Palliative Care Australia 2018).

Patients, with support from their family or carer and treating team, should be encouraged to consider appointing a substitute decision-maker and to complete an advance care directive.

Refer to Step 6 for a more detailed description of managing patients with recurrent, residual or metastatic disease.

More information

These online resources are useful:

The team should support the patient to participate in research or clinical trials where available and appropriate. Many emerging treatments are only available on clinical trials that may require referral to certain trial centres.

For more information visit the Cancer Australia website.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

  • assistance for dealing with emotional and psychological issues, including body image concerns, fatigue, quitting smoking, traumatic experiences, existential anxiety, treatment phobias, anxiety/depression, interpersonal problems and sexuality concerns
  • potential isolation from normal support networks, particularly for rural patients who are staying away from home for treatment
  • management of physical symptoms such as pain, fatigue, cough, breathlessness and halitosis
  • physical distress caused by breathlessness and coughing, which may be alleviated through a referral to allied health professionals (physiotherapy, occupational therapy, exercise physiologist or pulmonary rehabilitation); non-pharmacological strategies may be beneficial in breathlessness management (CareSearch 2019a) (note: if oxygen is medically indicated, this can be arranged through the relevant state aids and equipment program)
  • hoarseness may require referral to a speech therapist or ENT specialist
  • halitosis, which can occur if there is a necrotic tumour in the oropharynx or the lungs – patients need to be alerted to possible symptoms and what to do
  • haemoptysis (CareSearch 2019b) – ensure patients understand how to manage haemoptysis and obtain medical support
  • managing and taking medications – referral to a pharmacist may be required
  • decline in mobility or functional status as a result of treatment
  • assistance with beginning or resuming regular exercise with referral to an exercise physiologist or physiotherapist (COSA 2018; Hayes et al. 2019).

Early involvement of general practitioners may lead to improved cancer survivorship care following acute treatment. General practitioners can address many supportive care needs through good communication and clear guidance from the specialist team (Emery 2014).

Patients, carers and families may have these additional issues and needs:

  • financial issues related to loss of income (through reduced capacity to work or loss of work) and additional expenses as a result of illness or treatment
  • advance care planning, which may involve appointing a substitute decision-maker and completing an advance care directive
  • legal issues (completing a will, care of dependent children) or making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability.

Cancer Council’s 13 11 20 information and support line can assist with information and referral to local support services. Quitline 13 78 48 can provide information and support to quit smoking.

For more information on supportive care and needs that may arise for different population groups, see A and B, and special population groups.

Rehabilitation may be required at any point of the care pathway. If it is required before treatment, it is referred to as prehabilitation (see section 3.6.1).

All members of the multidisciplinary team have an important role in promoting rehabilitation. Team members may include occupational therapists, speech pathologists, dietitians, social workers, psychologists, physiotherapists, exercise physiologists and rehabilitation specialists.

To maximise the safety and therapeutic effect of exercise for people with cancer, all team members should recommend that people with cancer work towards achieving, and then maintaining, recommended levels of exercise and physical activity as per relevant guidelines. Exercise should be prescribed and delivered under the direction of an accredited exercise physiologist or physiotherapist with experience in cancer care (Vardy et al. 2019). The focus of intervention from these health professionals is tailoring evidence-based exercise recommendations to the individual patient’s needs and abilities, with a focus on the patient transitioning to ongoing self-managed exercise.

Other issues that may need to be dealt with include managing cancer-related fatigue, improving physical endurance, achieving independence in daily tasks, optimising nutritional intake, returning to work and ongoing adjustment to cancer and its sequels. Referrals to dietitians, psychosocial support, return-to-work programs and community support organisations can help in managing these issues.

The lead or nominated clinician should take responsibility for these tasks:

  • discussing treatment options with patients and carers, including the treatment intent and expected outcomes, and providing a written version of the plan and any referrals
  • providing patient and carers with information about the possible side effects of treatment, managing symptoms between active treatments, how to access care, self-management strategies and emergency contacts
  • encouraging patients to use question prompt lists and audio recordings, and to have a support person present to aid informed decision making
  • initiating a discussion about advance care planning and involving carers or family if the patient wishes.

The general practitioner plays an important role in coordinating care for patients, including helping to manage side effects and other comorbidities, and offering support when patients have questions or worries. For most patients, simultaneous care provided by their general practitioner is very important.

The lead clinician, in discussion with the patient’s general practitioner, should consider these points:

  • the general practitioner’s role in symptom management, supportive care and referral to local services
  • using a chronic disease management plan and mental health care management plan
  • how to ensure regular and timely two-way communication about:
  • the treatment plan, including intent and potential side effects
  • supportive and palliative care requirements
  • the patient’s prognosis and their understanding of this
  • enrolment in research or clinical trials
  • changes in treatment or medications
  • the presence of an advance care directive or appointment of a substitute decision-maker
  • recommendations from the multidisciplinary team.
More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.