Sections

Guidelines

Guidelines Summary

Lung Cancer Screening

Guidelines on lung cancer screening have been issued by the following organizations:

American Cancer Society (ACS)
American College of Chest Physicians (CHEST)
American Association for Thoracic Surgery (AATS)
National Comprehensive Cancer Network (NCCN)
U.S. Preventive Services Task Force (USPSTF)

Most of the guidelines recommend offering annual screening with low-dose, computed tomography (LDCT) scanning to patients aged 50 to 80 years who have at least a 20 pack-year smoking history and either continue to smoke or have quit within the past 15 years.^{[231, 46, 64, 65, 232]}CHEST weakly recommends screening in patients who meet those criteria, and strongly recommends screening in patients age 55 to 77with a 30 pack-year smoking history.^[46]The USPSTF recommends discontinuing screening once 15 years have gone by since the patient stopped smoking, or if the patient develops a health problem that "substantially limits life expectancy or the ability or willingness to have curative lung surgery."^[65]

The AATS recommends annual screening with LDCT from age 55 to 79 years in persons with a 30 pack-year history of smoking, with the option of starting screening at age 50 years in persons with a 20 pack-year history who have an additional cumulative risk of developing lung cancer of 5% or greater over the following 5 years. Additionally, the AATS recommends annual screening to detect second primary lung cancer in long-term cancer survivors aged 55 to 79 years.^[232]

The NCCN guidelines recommend starting screening at age 50 in patients with at least a 20 pack-year smoking history who are at high risk. The NCCN notes that evidence from randomized trials supports screening up to age 77 years, but screening beyond age 77 years may be considered as long as patient's functional status and comorbidity allow consideration for curative intent therapy. High risk is defined as the presence of one or more of the following risk factors^[64]:

Radon exposure (documented sustained and substantial)
Occupational exposure to lung carcinogens (eg, silica, cadmium, asbestos, arsenic, beryllium, chromium, diesel fumes, nickel, coal smoke, soot)
Cancer history (lymphomas, cancers of the head and neck, or smoking-related cancers)
Family history of lung cancer in first-degree relatives
Chronic obstructive pulmonary disease or pulmonary fibrosis
Second-hand smoke exposure

The NCCN advises that patients are not eligible for lung cancer screening if they have symptoms of lung cancer, a past history of lung cancer, or functional status and/or comorbidity that would prohibit curative intent treatment.

The groups all agree that the shared decision making is required and should include a discussion of benefits and risks.

None of the guidelines recommend using chest radiography or sputum cytology to screen asymptomatic patients for lung cancer.

ACCP Diagnosis and Management Guidelines

The American College of Chest Physicians (CHEST) updated its comprehensive set of lung cancer guidelines in 2013. The guideline set of more than 275 recommendations includes an executive summary of current recommendations for diagnosis and treatment, along with additional recommendations for screening, chemoprevention and treatment of tobacco use in patients with lung cancer.^[79]

Diagnosis of Pleural Abnormalities

The updated ACCP guidelines recommendations for diagnosis of pleural abnormalities include the following^[79]:

The least invasive and safest method (bronchoscopy with transbronchial needle aspiration, endobronchial ultrasound-guided needle aspiration, endoscopic ultrasound-guided needle aspiration, transthoracic needle aspiration, or mediastinoscopy) should be used to establish a diagnosis in individuals who have extensive infiltration of the mediastinum based on radiographic studies and no evidence of extrathoracic metastatic disease (negative positron emission tomography scan)
For individuals who have a solitary extrathoracic site suspicious of a metastasis, tissue confirmation of the metastatic site is recommended if a fine-needle aspiration (FNA) or biopsy of the site is feasible
In individuals in whom biopsy of a metastatic site would be technically difficult, it is recommended that diagnosis of the primary lung lesion be obtained by the least invasive method
In patients suspected of having lung cancer who have an accessible pleural effusion, ultrasound-guided thoracentesis is recommended to diagnose the cause of the pleural effusion
If pleural fluid cytology is negative, pleural biopsy (via image-guided pleural biopsy, medical or surgical thoracoscopy) is recommended as the next step

Diagnosis of Primary Tumor

The updated ACCP guidelines recommendations for diagnosis of primary tumor include the following^[79]:

If lung cancer is suspected and sputum cytology is negative for carcinoma, further testing should be performed
In patients who have a central lesion, bronchoscopy should be used to confirm the diagnosis; further testing should be performed if bronchoscopy results are non-diagnostic and suspicion of lung cancer remains
As an adjunct imaging modality when a tissue sample is required due to diagnostic uncertainty or poor surgical candidacy, radial endobronchial ultrasonography can confirm in real time the ideal location of bronchoscopic sampling and increase the diagnostic yield over conventional bronchoscopy for peripheral nodules
With peripheral lung lesions difficult to reach with conventional bronchoscopy, electromagnetic navigation guidance can be used if the equipment and the expertise are available; if electromagnetic navigation is not available, transthoracic needle aspiration (TTNA) is recommended
In patients who have a peripheral lesion, and who require tissue diagnosis before further management can be planned, TTNA is diagnostic option; however, further testing should be performed if TTNA results are non-diagnostic and suspicion of lung cancer remains
The diagnosis of non–small cell lung cancer (NSCLC) made on cytology (sputum, TTNA, bronchoscopic specimens, or pleural fluid) is reliable. However, adequate tissue must be obtained to accurately define the histologic type and to perform molecular analysis when applicable.

Treatment of Clinical Stage I and II NSCLC

The updated ACCP guidelines recommendations for treatment of clinical stage I and II NSCLC include^[79]:

Surgical resection is the primary and preferred treatment approach for patients with no medical contraindications and a lobectomy rather than sub-lobar resection is preferred; however, in patients with major increased risk of perioperative mortality or competing causes of death (due to age-related or other co-morbidities), an anatomic sub-lobar resection (segmentectomy) over a lobectomy is suggested
Patients should be evaluated by a thoracic surgical oncologist even if they are considered for nonsurgical therapies such as percutaneous ablation or stereotactic body radiation therapy
For clinical stage I patients, a minimally invasive approach such as video-assisted thoracoscopy surgery (VATS) is preferred over a thoracotomy for anatomic pulmonary resection
For patients with in whom a complete resection can be achieved, a sleeve or bronchoplastic resection is suggested over a pneumonectomy
For patients with clinical stage I NSCLC who cannot tolerate a lobectomy or segmentectomy, stereotactic body radiation therapy (SBRT) and surgical wedge resection are suggested over no therapy
The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit
The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit

Treatment of Clinical Stage III NSCLC

The updated ACCP guidelines recommendations for treatment of clinical Stage III NSCLC include the following^[79]:

Combined chemoradiotherapy is preferred over radiotherapy alone in most subsets of patients and concurrent chemoradiotherapy is recommended over sequential chemoradiotherapy
Consolidation chemotherapy or targeted therapy following definitive chemoradiation is not recommended
Neoadjuvant therapy followed by surgery is neither clearly better nor clearly worse than definitive chemoradiation
Postoperative radiotherapy improves local control without improving survival
For stage III disease on chemoradiation with response after two cycles of chemotherapy , durvalumab should be added adjuvantly.

Treatment of Clinical Stage IV NSCL

The updated ACCP guidelines recommendations for treatment of clinical stage IV NSCLC include the following^[79]:

The treatment of stage IV NSCLC should be specific for particular histologic subtypes and clinical patient characteristics and according to the presence of specific genetic mutations.
Both erlotinib and gefitinib as first-line therapy in patients with stage IV NSCLC and documented EGFR mutations based on superior response rates, progression-free survival and toxicity profiles compared with platinum-based doublets
Pemetrexed should be restricted to patients with nonsquamous histology (adenocarcinoma)
Bevacizumab in combination with chemotherapy (and as continuation maintenance) should be restricted to patients with nonsquamous histology and an Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0 to 1
The use of maintenance therapy with either pemetrexed or erlotinib should be considered after four cycles of first-line therapy in those patients without evidence of disease progression
The use of second- and third-line therapy is recommended in those patients retaining a good PS (1-2)
In the elderly and in patients with a poor PS, the use of two-drug, platinum-based regimens is preferred.
Palliative care should be initiated early in the course of therapy for stage IV NSCLC

Palliative Care

The updated ACCP guidelines recommendations for palliative and end-of-life care include the following^[79]:

For patients with stage IV lung cancer and/or a high symptom burden, palliative care combined with standard oncology care should be introduced early in the treatment course
Begin conversations about the patient's prognosis and goals of care at the time of the diagnosis, and continue these throughout the course of the illness
All physicians caring for patients with advanced lung cancer should initiate conversations about the goals of care, the pros and cons of life-sustaining treatment and end-of-life care options

Molecular Testing and Treatment

International evidence-based guidelines jointly published by the College of American Pathologists (CAP), the International Association for the Study of Lung Cancer (IASLC), and the Association for Molecular Pathology (AMP) in 2013 recommend all lung cancer patients with adenocarcinomas should be tested for the genetic abnormalities that indicate suitability for treatment with targeted agents, irrespective of clinical variables such as sex, ethnicity, or smoking status.^[57] These guidelines were endorsed by the American Society for Clinical Oncology (ASCO) in 2014.^[233]

National Comprehensive Cancer Network recommendations

In patients with adenocarcinoma, large cell NSCLC, and NSCLC not otherwise specified, the NCCN recommends the following molecular testing, conducted as part of broad molecular profiling^[89]:

EGFR mutation (category 1)
ALK (category 1)
KRAS
ROS1
BRAF
NTRK 1/2/3
MET exon 14 skipping
RET testing
Programmed death ligand 1( PD-L1) testing (category 1)

In patients with squamous cell NSCLC, the NCCN recommends considering the following molecular testing, conducted as part of broad molecular profiling:

EGFR mutation
ALK
ROS1
BRAF
MET exon 14 skipping
RET
PD-L1 testing (category 1)

For patients with a sensitizing EGFR mutation, the NCCN recommends the following for first-line therapy:

Osimertinib (preferred; also recommended for subsequent therapy)
Afatinib
Erlotinib
Dacomitinib
Gefitinib
Erlotinib + ramucirumab
Erlotinib + bevacizumab (nonsquamous)

For EGFR exon 20 insertion mutation positive cases, the NCCN recommends amivantamab-vmjw for subsequent therapy.

For ALK rearrangement–positive patients, the NCCN recommends the following for first-line therapy:

Alectinib (preferred)
Brigatinib
Ceritinib
Crizotinib (useful for patients with performance status 0-4)
Lorlatinib

For subsequent therapy in ALK rearrangement–positive patients, the NCCN recommends the following:

Alectinib
Brigatinib
Ceritinib
Lorlatinib

For ROS1 rearrangement–positive patients, the NCCN recommends the following for first-line therapy:

Ceritinib
Crizotinib
Entrectinib

For subsequent therapy in ROS1 rearrangement–positive patients, the NCCN recommends the following:

Lorlatinib
Entrectinib

For BRAF V600E mutation–positive patients, the NCCN recommends dabrafenib/trametinib for first-line as well as subsequent therapy.

For NTRK 1/2/3 gene fusion–positive patients, the NCCN recommends larotrectinib or entrectinib for first-line as well as subsequent therapy.

For patients with MET exon 14 skipping mutation, the NCCN recommends the following for both first-line and subsequent therapy:

Capmatinib
Crizotinib
Tepotinib

For RET rearrangement–positive patients, the NCCN recommends the following for both first-line and subsequent therapy:

Selpercatinib
Pralsetinib
Cabozantinib
Vandetanib

For patients with PD-L1 ≥1%, the NCCN recommends the following for first-line therapy:

Pembrolizumab
(Carboplatin or cisplatin)/pemetrexed/pembrolizumab (nonsquamous)
Carboplatin/paclitaxel/bevacizumab/atezolizumab (nonsquamous)
Carboplatin/(paclitaxel or albumin-bound paclitaxel)/pembrolizumab (squamous)
Carboplatin/albumin-bound paclitaxel/atezolizumab (nonsquamous)
Nivolumab/ipilimumab

For MET exon 14 skipping mutation–positive patients, the NCCN recommends capmatinib or crizotinib for first-line as well as subsequent therapy.

For MET rearrangment–positive patients, the NCCN recommends selpercatinib, cabozantinib, or vandetanib for first-line as well as subsequent therapy.

ESMO recommendations

Guidelines from the European Society for Medical Oncology (ESMO) contain the following recommendations on molecular testing in patients with NSCLC^[234]:

EGFR mutation status should be systematically analysed in advanced NSCC. At a minimum, when resources or material are limited, the most common activating mutations (exon 19 deletion, exon 21 L858R point mutation) should be determined; T790M mutation testing is mandatory on disease relapse.
Testing for ALK rearrangement should be systematically carried out in advanced nonsquamous NSCLC.
Testing for ROS1 rearrangement should be systematically carried out in advanced NSCLC.
BRAF V600 mutation status should be systematically analysed in advanced NSCLC
Molecular EGFR and ALK testing are not recommended in patients with a confident diagnosis of squamous cell NSCLC, except in unusual cases (eg, never/former light smokers or long-time ex-smokers)
If available, multiplex platforms (NGS) for molecular testing are preferable.
PD-L1 inmunohistochemistry should be systematically determined in advanced NSCLC.

In patients with metastatic NSCLC with positive molecular tests, ESMO treatment recommendations are as follows:

Sensitizing EGFR mutation: Osimertinib; gefitinib; erlotinib, erlotinib + bevacizumab, erlotinib + ramucirumab, afatinib, dacomitinib, gefitinib/carboplatin/pemetrexed
ALK translocation: Alectinib, crizotinib, ceritinib, brigatinib
BRAF V600 mutation: Dabrafenib/trametinib
ROS1 translocation: Crizotinib

Video-Assisted thoracoscopy surgery (VATS)

NCCN practice guidelines recommend that VATS or minimally invasive surgery (including robotic-assisted approaches) be strongly considered for patients who have no anatomic or surgical contraindications, provided that standard oncologic and dissection principles of thoracic surgery are not compromised. The guideline notes that in high-volume centers with significant VATS experience, VATS lobectomy in selected patients results in improved early outcomes (ie, decreased pain, reduced hospital length of stay, more rapid return to function, fewer complications) without compromise of cancer outcomes.^[89]

Treatment of Stage IV Disease

The American Society of Clinical Oncology (ASCO) published its most recent full update of guidelines on systemic therapy for stage IV NSCLC in 2017.^[225] ASCO and Ontario Health (Cancer Care Ontario)(OH[CCO]) published a partial update on treatment of stage IV NSCLC without driver alterations in 2020.^[226]In addition, ASCO recommends early palliative care assistance for all patients with stage IV NSCLC, because it improves survival and well-being in patients with this incurable condition.^[225]

For patients with high programmed death ligand 1 (PD-L1) expression (tumor proportion score [TPS] ≥ 50%), non–squamous cell carcinoma (non-SCC), and performance status (PS) 0 to 1, the ASCO/OH(CCO) guidelines advise that single-agent pembrolizumab should be offered, and that the following regimens may be offered^[226]:

Pembrolizumab/carboplatin/pemetrexed
Atezolizumab/carboplatin/paclitaxel/bevacizumab
Atezolizumab/carboplatin/nab-paclitaxel

For eligible patients with negative or low-positive PD-L1 expression (TPS 0% or 1-49%), non-SCC, and PS 0 to 1, pembrolizumab/carboplatin/pemetrexed should be offered, while atezolizumab/carboplatin/paclitaxel/bevacizumab may be offered. For patients who have contraindications to immunotherapy or who decline it, the guidelines recommend offering standard chemotherapy with two-drug combinations, preferably platinum based.

For patients with high PD-L1 expression (TPS ≥ 50%), SCC, and PS 0 to 1, single-agent pembrolizumab should be offered but pembrolizumab in combination with carboplatin/paclitaxel or nab-paclitaxel may be offered. Single-agent pembrolizumab may also be offered to patients with low-positive PD-L1 expression (TPS 1% to 49%), non-SCC, and PS 0 to 1 who are ineligible for or decline platinum-based doublet therapy.

In 2021, ASCO/OH(CCO) issued joint guidelines on treatment of stage IV NSCLC with alterations in any of the following molecular targets^[227]:

Epidermal growth factor receptor ( EGFR)
Anaplastic lymphoma kinase ( ALK)
ROS1 fusions
BRAF V600e mutations
RET fusions
MET exon 14 skipping mutations
NTRK fusions

EGFR mutations

First-line therapy:

In patients with T790M, L858R, or exon 19 deletion mutations, osimertinib should be offered. If osimertinib is not available, gefitinib with chemotherapy or dacomitinib may be offered.
Other options that may be offered include afatinib, erlotinib/bevacizumab, erlotinib/ramucirumab, gefitinib, erlotinib, or icotinib
In patients with a PS of 3, an EGFR tyrosine kinase inhibitor (TKI) may be offered.
In patients with EGFR mutations other than exon 20 insertion mutations, T790M, L858R, or exon 19 deletion alterations, afatinib may be offered.
In patients with EGFR exon 20 insertion mutation causing resistance to first- and second-generation EGFR TKIs, doublet chemotherapy with or without bevacizumab or standard treatment for stage IV NSCLC without driver mutations may be offered.

Second-line therapy:

In patients who did not receive osimertinib and who have an EGFR T790M mutation at the time of progressive disease, osimertinib should be offered.

In patients with any other EGFR mutation whose disease has progressed on EGFR TKIs, or those whose disease has progressed on osimertinib, treatment based on NSCLC without driver mutations may be offered.

ALK alterations

First-line therapy:

Alectinib or brigatinib should be offered.
If alectinib and brigatinib are not available, ceritinib or crizotinib should be offered.

Second-line therapy

If alectinib or brigatinib was given in the first-line setting, lorlatinib may be offered.
If crizotinib was given in the first-line setting, then alectinib, brigatinib, or ceritinib should be offered.

Third-line therapy

If crizotinib was given in the first-line setting and alectinib, brigatinib, or ceritinib in the second-line setting, then lorlatinib may be offered, or standard treatment for NSCLC without driver mutations may be offered.

ROS1 fusions

First-line treatment

Any of the following may be offered:

Crizotinib
Entrectinib
Standard treatment for NSCLC without driver mutations
Ceritinib
Lorlatinib

Second-line treatment:

If ROS1-targeted therapy was given in the first-line setting, standard treatment for NSCLC without driver mutations should be offered
If nontargeted therapy was given in the first-line setting, crizotinib, ceritinib, or entrectinib may be offered

BRAF mutations

See the list below:

For first-line therapy in patients with the BRAF V600E mutation, dabrafenib/trametinib or standard treatment for NSCLC without driver mutations may be offered.
For second-line therapy in patients with the BRAF V600E mutation who received BRAF/MEK-targeted therapy (dabrafenib/trametinib) in the first-line setting, standard treatment for NSCLC without driver mutations should be offered.
For second-line therapy in patients who did not receive BRAF-targeted therapy in the first-line setting, dabrafenib/trametinib or dabrafenib or vemurafenib alone may be offered.
For second-line therapy in patients with BRAF mutations other than V600E, standard treatment for NSCLC without driver mutations should be offered.

MET exon 14 skipping mutations

See the list below:

For second-line treatment in patients who have MET abnormalities other than exon 14 skipping mutations or who received MET-targeted therapy in the first-line setting, standard treatment for NSCLC without driver mutations should be offered.
For second-line treatment in patients with an MET exon 14 skipping mutation who previously received or were ineligible for first-line chemotherapy with or without immunotherapy (ie, if MET-targeted therapy was not given in the first-line setting), capmatinib or tepotinib may be offered.

RET fusions

See the list below:

For second-line therapy in patients who received RET-targeted therapy in the first-line setting, standard treatment for NSCLC without driver mutations may be offered.
For second-line therapy in patients who did not receive RET-targeted therapy in the first-line setting, selpercatinib or (provisionally) pralsetinib may be offered.

NTRK fusions

See the list below:

For first-line therapy, entrectinib or larotrectinib or standard treatment for NSCLC without driver mutations may be offered.
For second-line therapy in patients who received NTRK-targeted therapy in the first-line setting, standard treatment for NSCLC without driver mutations may be offered.
For second-line therapy in patients who did not receive NTRK-targeted therapy in the first-line setting, entrectinib or larotrectinib may be offered.

Radiation Therapy for Locally Advanced Disease

In 2015, the American Society for Radiation Oncology (ASTRO) released evidence-based guidelines for definitive and adjuvant radiotherapy in locally advanced NSCLC.^{[235, 236]} The American Society for Clinical Oncology has endorsed these guidelines.^[237]

The guidelines cover patients with stage II or III locally advanced NSCLC whose disease is unresectable, and patients with stage II or III disease who are eligible for surgery. Key recommendation include the following^{[235, 236]}:

Curative-intent Treatment

Concurrent chemoradiation improves local control and overall survival and is recommended over sequential chemotherapy followed by radiation or radiation therapy alone
The standard dose-fractionation of radiation with concurrent chemotherapy is 60 Gy given in fractions of 2 Gy once per day over 6 weeks
Dose escalation beyond 60 Gy has no demonstrated benefit.
There is no role for the routine use of induction chemotherapy beforechemoradiation
Current data fail to support routine use of consolidation chemotherapy after chemoradiotherapy, but this remains an option for patients who did not receive full systemic chemotherapy doses during radiotherapy.
The ideal concurrent chemotherapy regimen has not been determined. The two most common regimens are cisplatin/etoposide and carboplatin/paclitaxel.
For patients who cannot tolerate chemoradiation, sequential chemotherapy followed by radical radiation improves overall survival when compared to radiotherapy alone.

Adjunctive Therapy

Radiotherapy alone may be used for patients ineligible for combined modality treatment; it may offer better tolerability, but poorer survival.
Postoperative radiotherapy may be recommended for patients with complete resection of N2 disease to improve local control, but should be delivered sequentially after adjuvant chemotherapy.
For patients receiving postoperative radiotherapy for R0 disease, conventionally fractionated doses in the range of 50 Gy to 54 Gy (in 1.8-2.0 Gy/day) should be used.
Postoperative radiotherapy with conventionally fractionated doses in the range of 54 Gy to 60 Gy (in 1.8-2.0 Gy/day) to improve local control for patients with R1 disease (incomplete resection), to be given either concurrently or sequentially with chemotherapy.
Patients with R2 disease may be candidates for postoperative radiotherapy with conventionally fractionated doses of at least 60 Gy (in 1.8-2.0 Gy/day fraction size) to improve local control, to be given either concurrently or sequentially with chemotherapy.

COVID-19

The American College of Surgeons has released a guideline on COVID-19–related triage of patients with thoracic cancer.^[238] As a general recommendation, the guideline recommends that determination of case status (ie, risk of death time frame) be made by Division, ideally in a multi-clinician setting (case review conference).

Suggested consent language: You are being offered surgery now, because at this time we feel that your risk of being harmed by infections, including coronavirus, within the hospital is low, and that delaying surgery could reduce your chances of being cured of cancer. It is not possible to know either the risk of delaying surgery or the chance of getting an infection with perfect accuracy, but I did consult my colleagues and it is our group’s opinion that surgery is a reasonable thing to do.

Specific guideline recommendations are divided into three phases, depending on the COVID-19 status at a given hospital.

Phase I – Semi-urgent Setting (Preparation Phase)

Features of this phase are as follows:

The hospital has few COVID-19 patients
Resources are not exhausted
ICU ventilator capacity exists
The COVID-19 trajectory is not in rapid escalation phase

In phase I, surgery should be restricted to patients whose survival is likely to be compromised if surgery not performed within next 3 months. The following cases need to be done as soon as feasible (recognizing that the status of each hospital is likely to evolve over next week or two):

Solid or predominantly solid (> 50%) lung cancer or presumed lung cancer > 2 cm, clinical node negative
Node-positive lung cancer
Post–induction therapy cancer
Chest wall tumors of high malignant potential not manageable by alternative therapy
Staging to start treatment (mediastinoscopy, diagnostic VATS for pleural dissemination)
Symptomatic mediastinal tumors – diagnosis not amenable to needle biopsy
Patients enrolled in therapeutic clinical trials

Cases that should be deferred include the following:

Predominantly ground glass (< 50% solid) nodules or cancers
Solid nodule or lung cancer < 2 cm
Indolent histology (eg, carcinoid, slowly enlarging nodule)
Pulmonary oligometastases - unless clinically necessary for pressing therapeutic or diagnostic indications (ie, surgery will impact treatment)
Patients unlikely to separate from mechanical ventilation or likely to have prolonged ICU needs (ie, particularly high-risk patients)
Tracheal resection (unless aggressive histology)
Bronchoscopy
Upper endoscopy
Tracheostomy

The following alternative treatment approaches can be considered (assuming resources permit):

If the patient is eligible for adjuvant therapy, neoadjuvant therapy (eg, chemotherapy for 5-cm lung cancer)
Stereotactic ablative radiotherapy (SABR)
Ablation (eg, cryotherapy, radiofrequency ablation)
Stent for obstructing cancers, then treat with chemoradiation
Debulking (endobronchial tumor) only in circumstance where alternative therapy is not an option due to increased risk of aerosolization (eg, stridor, post-obstructive pneumonia not responsive to antibiotics)
Nonsurgical staging (endobronchial ultrasound, imaging, interventional radiology biopsy)
Follow patients after their neoadjuvant for “local only failure” (ie, salvage surgery)
Extending chemotherapy (additional cycles) for patients completing a planned neoadjuvant course

Phase II – Urgent Setting

Features of this phase are as follows:

Many COVID 19 patients
ICU and ventilator capacity limited
OR supplies limited or
COVID trajectory within hospital in rapidly escalating phase

Surgery should be restricted to patients whose survival is likely to be compromised if surgery is not performed within the next few days. Cases that need to be done as soon as feasible (recognizing that the hospital’s status is likely to progress over next few days):

Tumor-associated infection – compromising, but not septic (eg, debulking for post obstructive pneumonia)
Management of surgical complications (hemothorax, empyema, infected mesh) – in a hemodynamically stable patient

All thoracic procedures typically scheduled as routine/elective (ie, not add-ons) should be deferred.

Alternative treatment approaches that are recommended, assuming resources permit, are as follows:

Transfer patient to a hospital that is in Phase I
If the patient is eligible for adjuvant therapy, give neoadjuvant therapy
SABR
Ablation (eg, cryotherapy, radiofrequency ablation)
Reconsider neoadjuvant therapy as definitive chemoradiation therapy, and follow patients for “local only failure” (ie, salvage surgery)

Phase III

In this phase, hospital resources are all routed to COVID-19 patients, the hospital has no ventilator or ICU capacity, and OR supplies are exhausted. Surgery should be restricted to patients whose survival is likely to be compromised if surgery is not performed within next few hours.

Cases that need to be done as soon as feasible (status of hospital likely to progress in hours) are as follows:

Threatened airway
Tumor-associated sepsis
Management of surgical complications – unstable patient (active bleeding not amenable to nonsurgical management, dehiscence of airway, anastomotic leak with sepsis)

All other cases should be deferred. Recommended alternative treatments are the same as for Phase II.

Medication

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Media Gallery

Non–small cell lung cancer. Symptoms and signs of lung cancer.
Non–small cell lung cancer. Diagnostic approach for possible lung cancer.
Staging workup for non–small cell lung cancer.
Treatment recommendations and future research directions in the management of non–small cell lung cancer.
Non–small cell lung cancer. Performance status scales for patients with cancer.
Non–small cell lung cancer. Prognostic factors for lung cancer.
Non–small cell lung cancer. Bronchoscopy. A large central lesion was diagnosed as non–small cell carcinoma.
Non–small cell lung cancer. Left pleural effusion and volume loss secondary to non–small cell carcinoma of the left lower lobe. The pleural effusion was sampled and found to be malignant; therefore, the lesion is inoperable.
Non–small cell lung cancer. Left upper collapse is almost always secondary to endobronchial bronchogenic carcinoma.
Non–small cell lung cancer. Complete left lung collapse secondary to bronchogenic carcinoma of left mainstem bronchus.
Non–small cell lung cancer. A cavitating right lower lobe squamous cell carcinoma.
Non–small cell lung cancer. CT scan shows cavitation and air-fluid level.
Non–small cell lung cancer. Patient has right lower lobe opacity. This is not well circumscribed and was found to be a squamous cell carcinoma.
Lung cancer, small cell. Contrast-enhanced CT scan of the chest shows a large left lung and a hilar mass, with invasion of the left pulmonary artery.
Lung cancer, small cell. Coronal positron emission tomogram shows abnormal areas of increased metabolic activity in the left hilar and left adrenal regions consistent with a hilar tumor with left adrenal metastasis.
Lung cancer, small cell. Whole-body nuclear medicine bone scanning with anterior and posterior images reveal multiple abnormal areas of increased radiotracer activity in the pelvis, spine, ribs, and left scapula. These findings are consistent with bony metastatic disease. The bones are commonly affected in patients with small-cell lung cancer.
Lung squamous carcinoma 4x: low power magnification of moderately differentiated squamous cell carcinoma showing irregular nests of tumor cells with focal areas of keratinization (pink-orange areas).
Lung squamous carcinoma 20x: higher power magnification of moderately differentiated squamous cell carcinoma showing focal areas of keratinization (pink-orange areas) just to the right of center.
Lung adenocarcinoma 4x: low power magnification of moderately differentiated adenocarcinoma showing rounded nests of pale staining tumor cells with gland lumina within some of the clusters.

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Author

Winston W Tan, MD, FACP Associate Professor of Medicine, Mayo Medical School; Consultant and Person-in-Charge of Genitourinary Oncology-Medical Oncology, Division of Hematology/Oncology, Department of Internal Medicine, Mayo Clinic Jacksonville; Vice Chairman, Division of Hematology/Oncology Education, Chair, Cancer Survivorship Program, Associate Chair, Department of Medicine Faculty Development, Mayo Clinic Florida; Vice President, Florida Society of Clinical Oncology

Winston W Tan, MD, FACP is a member of the following medical societies: American College of Physicians, American Society of Clinical Oncology, American Society of Hematology, Philippine Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Syed Huq, MD Fellow, Division of Hematology-Oncology, Department of Internal Medicine, University of Missouri-Columbia School of Medicine, Ellis Fischel Cancer Center

Syed Huq, MD is a member of the following medical societies: American Medical Informatics Association, American Society of Hematology, American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Nagla Abdel Karim, MD, PhD Director of Early Therapeutics, Inova Schar Cancer Institute; Professor of Medicine, University of Virginia School of Medicine

Nagla Abdel Karim, MD, PhD is a member of the following medical societies: American Medical Association, American Society of Clinical Oncology, Egyptian American Medical Association, Egyptian Cancer Society, International Association for the Study of Lung Cancer

Disclosure: Nothing to disclose.

Acknowledgements

Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians