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.