1. National Optimal Clinical Pathway for suspected and confirmed lung cancer:
Referral to treatment
Note: this was previously circulated for discussion as an “aspirational” pathway but following feedback has been designated the optimal pathway
UPDATE 2017
Summary
This optimal pathway is designed to meet the waiting time targets as set out in the Independent Cancer Taskforce report. In addition it will reduce delays within primary care relating to chest X-ray reporting and referral times with a potential to shorten the time to diagnosis by 2 to 4 months. This is because we know that in England, chest X-ray rates increase substantially from 4 months prior to diagnosis of lung cancer.
Use of guidelines
The diagnosis, staging and fitness assessments in this pathway should be completed with reference to the British Thoracic Society guidelines for the radical management of lung cancer and the NICE guidelines for the investigation and management of suspected lung cancer.
Maximum waiting times
The times in the pathway are the maximum allowed and the aim should be for the majority of patients diagnosed within 14 days and treated within 28. There is randomised controlled trial evidence that faster pathways improve outcomes.
Providers: a note for commissioners
The initial identification and referral of patients with suspected lung cancer is dependent on primary care. Prompt recognition, risk assessment and referral is essential to reduce delay in diagnosis and to reduce the high proportion of lung cancer patients who are diagnosed via emergency admissions. The majority of the lung cancer diagnostic, staging and treatment is provided by secondary and tertiary care, although primary care may be involved in providing supportive care throughout. Supportive, palliative and end of life care is provided by both primary and secondary care.
Notes:
Potential for reducing delay from CXR to CT and clinic to less than 24 hours
Potential avoidance of emergency admission
Allows triaged patients to be managed by primary or secondary care (see separate algorithms)
Rapid progress to treatment
Requirements:
Turnaround times have to be short, especially for radiology
Hot reporting of all CXRs and subsequent CTs
Daily respiratory medicine cancer clinic required
What’s new in the update?
CXR can be reported within 24 hours (rather than immediate reporting mandated) – added as some services achieving Chest X-ray, CT and clinic within 3 days
Additional direct to biopsy option where appropriate patients can be triaged direct from CT to rapid biopsy sufficient to allow treatment to proceed

2. Referral to treatment UPDATE 2017
National Optimal Clinical Pathway for suspected and confirmed lung cancer:
Referral to treatment UPDATE 2017 No GP
Hospitals referrals (A&E, internal or incidental findings) for suspected lung cancer
High clinical suspicion?
Maximum times
Urgent or routine CXR
Yes
Direct referral criteria (NICE) No
CXR suspicious of lung cancer? (reported before patient leaves dept or within 24 hours.)
CT within 24 hours if clinically indicated; inpatients seen within 48 hours by acute oncology, respiratory and/or palliative services
NICE referral guidance
Yes
Day -3-0
CT same day / within 72 hours
CT not indicated
CT suspicious of lung cancer? No
CT abnormal? No
Yes
Manage
Yes
Day 0-3
TRIAGE
(by radiology or respiratory medicine according to local protocol) Lung cancer suspected?
Yes No
Direct biopsy option*
Day 1-5
Fast track lung cancer clinic. Meet LCNS.
Diagnostic process plan / diagnostic planning meeting prior to clinic
Treatment of co-morbidity and palliation / treatment of symptoms
Lung cancer unlikely
Further management according to local protocol with options of further management of CT findings by primary care or secondary care (see separate detailed algorithm)
Suitable for potentially curative treatment?+
Yes No
Curative Intent Management pathway*
Test bundle requested at first OPA including at least: PET-CT and as required: detailed lung function and cardiac assessment / ECHO.
Meet with LCNS and receive information.
Will pathological diagnosis influence treatment and is potential treatment appropriate to patient’s wishes?
Throughout pathway:  • consider entry into a research trial • offer supportive & palliative care, e.g. by LCNS, GP, specialists in palliative care • encourage smoking cessation
Yes No
Investigations to yield maximum diagnostic AND staging information with least harm. Results available within 3 days for subtype and 10 days for molecular markers.
Clinical diagnosis or patient preference means biopsy not required.
Yes
Further investigation(s) indicated? No
Day 21
Full MDT discussion of treatment options
Yes
Yes
Further investigation(s)?
Further discussion needed?
No cancer: Manage/discharge No No
Day 28
Follow-up Lung Cancer Clinic
Cancer Confirmed and treatment options discussed. Research trial considered.
LCNS present
Day 33
OPA with treating specialist (within 3 working days)
*Refer to further pathway detail
Yes
Day 42
Further investigation(s)?
+ Low threshold for curative intent pathway; may discuss with wider MDT if unsure No
Day 62
Surgery
Specialist palliative care
Chemotherapy
Radiotherapy
First Treatment
Other palliative treatments
$ Some or all diagnosis and staging tests may be in a tertiary centre
Maximum times

3. Triage system for referrals to the lung cancer service: secondary care leads the management process
This pathway places the responsibility for managing all patients referred for suspected lung cancer within secondary care. It ensures patients with other conditions that may require secondary care are given appointments and patients not requiring secondary care are directed back to primary care without the need for an outpatient appointment in secondary care.
TRIAGE
Respiratory physician triages with reported CT according to clinical and radiological features
Lung cancer likely?
Yes No
Fast track lung cancer clinic.
Meet LCNS.
Diagnostic process plan / diagnostic planning meeting prior to clinic.
Treatment of co-morbidity and palliation / treatment of symptoms.
Non lung cancer pathway
Respiratory condition requiring urgent appointment including other cancer?
Lung cancer pathway
Yes No
Urgent respiratory clinic or other fast track cancer referral
Urgent non-respiratory condition?
Yes No
Urgent communication with GP or direct admission depending on condition found or suspected
Ongoing symptoms / need for non-urgent respiratory OPA?
Write to GP and patient
Yes No
Non-urgent respiratory OPA Including management of pulmonary nodules
GP meets/communicates with patient.
Still requires respiratory OPA?
Yes No
GP manages patient
Recommendations for the management of pulmonary nodule can be found in the British Thoracic Society guidelines on the investigation and management of pulmonary nodules

4. Triage system for referrals to the lung cancer service: primary care leads the management process
This pathways places the responsibility for managing patients that are unlikely to have lung cancer within primary care following a CT report that is not suspicious for lung cancer. This means fewer non-lung cancer patients are seen by the lung cancer services but relies on management of other conditions in primary care.
TRIAGE
Radiologist (with or without respiratory physician input triages according to CT findings
Yes No
Fast track lung cancer clinic.
Meet LCNS.
Diagnostic process plan / diagnostic planning meeting prior to clinic
Treatment of co-morbidity and palliation / treatment of symptoms
Non lung cancer pathway
Condition requiring urgent appointment including other cancer?
Lung cancer pathway
Yes No
Refer for urgent clinic / admission or other fast track cancer referral
Non-urgent condition?
Yes No
Manage in primary care or non-urgent referral
Management of pulmonary is included here
GP manages patient
Recommendations for the management of pulmonary nodules can be found in the British Thoracic Society guidelines on the investigation and management of pulmonary nodules.

5. Full MDT Discussion of treatment options or further investigation
National Optimum Curative Intent Management Pathway Detail
Patients who are potentially suitable for curative treatment often require a complex combination of investigations to ensure they are accurately diagnosed, staged and their fitness assessed. This means they are more likely to endure longer waits for treatment. Hospitals face different challenges owing to variability in capacity to provide different investigations. The aim of this pathway is therefore to fast track such patients by requesting tests concurrently, supported by pre-planned availability of urgent test appointments e.g. lung biopsy, bronchoscopy, endobronchial ultrasound, mediastinoscopy, ECHO and complex lung function. Reference should be made to the British Thoracic Society guidelines for the radical management of lung cancer and the NICE guidelines for the investigation and management of suspected lung cancer. To prevent delays in treatment, consider early notification of thoracic surgeons or clinical oncology to help with scheduling
Fast track lung cancer clinic
± diagnostic planning meeting / Diagnostic MDT
Meet lung cancer nurse specialist
Stage: Potentially T1-3 N0-2 M0 (N2 non-bulky; i.e. <3cm)
Or locally advanced; potential for radical RT?
May include selected patients with oligometastatic disease No
Yes
Potentially fit enough for treatment with curative intent and willing to consider this?
(Ensure low threshold for proceeding with work up for curative treatment) No
Yes
Simultaneous fast track:
Patients with borderline fitness$ add:
Preoperative rehabilitation
Shuttle walk test / CPEX / ECHO
Perfusion scan if required
Early cardiology assessment for cardiac co-morbidity
All patients:
Medical optimisation (incl. smoking cessation)
PET-CT (within 5 days)
Diagnostic and staging tests
Spirometry ±TLCO
Complete all tests within 14 days
Alert surgeons / clinical oncology
Usual diagnosis and staging pathway
Full MDT Discussion of treatment options or further investigation
Yes
Yes
Further investigation(s)?
Further discussion needed? No No
Follow-up Lung Cancer Clinic
Cancer Confirmed and treatment options discussed. Research trial considered.
LCNS present
OPA with treating specialist (within 3 days)
Yes
Further investigation(s)? No
First Treatment
$There is no agreed definition of borderline fitness. NICE QS 17 (Lung Cancer) defines this as a level of fitness that could lead to a greater than average morbidity or mortality from surgery. However, modern radiotherapy techniques mean that assessment for curative treatment can be applied at lower levels of fitness than defined in QS17.

6. Suggestive of Lung cancer
If preferred
GP 2WW referral
Target Office
Variation of NICE NG12 for Recognition and Referral for Suspected Lung Cancer to include Direct Access to CT (Grey shaded)
(Advice from Respiratory Physicians available at all stages)
CT Request by GP
Patient presents to GP
CXR
CT report to GP;
If cancer direct to 2WW
Unexplained
Dyspnoea
Cough
Resolved minor haemoptysis
High risk of lung cancer and clinical concern
Unexplained change in symptoms in patients with chronic respiratory disease
Persistent haemoptysis in smokers or ex-smokers who are aged 40 years and older
Consider Immediate referral for:
signs of superior vena caval obstruction
stridor.
Aged 40 years or older with haemoptysis, or
Aged 40 or older and any 2 of the following unexplained symptoms, or 1 symptom with a history of ever having smoked: :
Fatigue
Chest pain
Weight loss
Appetite loss
Aged 40 or older and any 1 of the following:
Finger clubbing
Supraclavicular lymphadenopathy or Persistent cervical lymphadenopathy
Chest signs consistent with lung cancer
Thrombocytosis.
Consider Risk Factors:
current or ex-smokers
smoking-related COPD
asbestos exposure
previous history of cancer (especially head and neck).
Other diagnosis
Normal
Suggestive of Lung cancer CT
Triage
Yes
Other
Observation or referral depending on symptoms / signs

7. National Optimal Pathway
Direct to biopsy variation
This pathway allows for early diagnostic biopsy where other tests are not required for staging and treatment. Such patients include those that have obvious advanced disease that is not suitable for treatment with curative intent. Patients potentially suitable for curative intent generally require a PET-CT to clarify staging and the most appropriate first diagnostic and staging investigation. Direct biopsy investigations include neck ultrasound guided biopsy, percutaneous lung biopsy (ambulatory), endobronchial ultrasound needle biopsy, pleural aspiration and pleural biopsy. The direct biopsy pathway has the potential to provide a rapid diagnosis for some patients where detailed staging and fitness investigations are not needed to guide management.
CT suspicious of lung cancer? No
Yes
Manage
Day 0-3
TRIAGE
(by radiology or respiratory medicine according to local protocol) Lung cancer suspected?
Suitable for potentially curative treatment?
Yes No
Will pathological diagnosis influence treatment and is potential treatment appropriate to patient’s wishes?
Yes No
Clinical diagnosis or patient preference means biopsy not required. No
Staging investigation not required to guide management No
Yes
Direct to biopsy; same day or within 3 days
Yes
Day 1-5
Fast track lung cancer clinic. Meet LCNS.
Diagnostic process plan / diagnostic planning meeting prior to clinic
Treatment of co-morbidity and palliation / treatment of symptoms
National Optimal Pathway