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Essential toolkit: lung cancer

This is the second in our series of resources from the Cancer Nursing Partnership to support nurses in delivering cancer recovery packages.
Pulmonary rehabilitation

Keep your learning up to date with our series of monthly toolkits to help support nurses in delivering recovery cancer care

This is the second in our series of resources from the Cancer Nursing Partnership to support nurses in delivering cancer recovery packages. Written by Cancer Nursing Partnership experts, each article will cover the essential facts about living with and beyond cancer, alongside a clinical revision guide to keep your learning up-to-date.

Disease prevalence

Lung cancer is the most commonly diagnosed cancer worldwide, with incidence rates continuing to increase in developing countries. Although survival in the first year has improved, five-year survival remains poor and it remains the leading cause of cancer mortality in the UK and the world (Calman et al 2011).

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Keep your learning up to date with our series of monthly toolkits to help support nurses in delivering recovery cancer care

This is the second in our series of resources from the Cancer Nursing Partnership to support nurses in delivering cancer recovery packages. Written by Cancer Nursing Partnership experts, each article will cover the essential facts about living with and beyond cancer, alongside a clinical revision guide to keep your learning up-to-date.

Disease prevalence

Lung cancer is the most commonly diagnosed cancer worldwide, with incidence rates continuing to increase in developing countries. Although survival in the first year has improved, five-year survival remains poor and it remains the leading cause of cancer mortality in the UK and the world (Calman et al 2011).


The social aspect of exercise and rehabilitation can contribute to the long-term well-being
for people who are living with and beyond lung cancer. Picture: Chris North

This is because it is common and the majority of people with lung cancer present late when treatment has a limited effect on mortality. In the UK, there are approximately 42,000 new cases of lung cancer diagnosed each year (CRUK 2013).

Survival and quality of life are significantly affected by lung cancer and although tobacco smoking causes around 85% of lung cancers, more than half of people at presentation are ex-smokers or have never smoked. Moreover, for around 7,000 people who develop lung cancer each year in the UK, the advancement of their disease is unrelated to smoking. Survival for patients with lung cancer is intimately related to the stage at diagnosis.  

Improving lung cancer survival rates to 25% by 2025 is part of a ten-year strategy aimed at maximising ways to improve survival (UKLCC  2015). This relationship between earlier diagnosis and improved clinical outcomes is acknowledged by NHS England and is a key aim of the cancer strategy (Achieving World Class Cancer Outcomes. A Strategy for England 2015-2020).

Risk factors

Reducing tobacco smoking has resulted in the largest reduction in cancer incidence in the UK and other developed countries. Further reduction of smoking is essential for prevention of many diseases and in lung cancer it is known that people who continue to smoke have worse outcomes at all stages.

The established smoking cessation services should be recommended to patients on the basis that this would improve survival and mortality.

Other risk factors include age, exposure to asbestos, radon gas and chemicals, as well as passive smoking. Adenocarcinoma in women has also been linked with genetic susceptibility (Truong et al 2010).

Diagnosis

The most common presenting symptoms are breathlessness, cough, haemoptysis, chest or shoulder pain and weight loss. All of these symptoms are non-specific and so awareness of combinations of symptoms in conjunction with baseline risk factors is the best way to identify people with lung cancer.

For the most effective treatment to be offered to patients, the diagnosis, stage and fitness assessment/performance status has to be accurate. This is complex, but essential, as multiple investigations are often required to obtain the maximum diagnostic and staging information sufficient to guide management, with least risk, from each test. To view the pathways for lung cancer, go to NICE pathways 

Types of lung cancer

Lung cancer is classified into non-small cell lung cancer (NSCLC), which accounts for the majority of cases, and small-cell cancer (SCLC) accounting for approximately 10%. NSCLC has two major sub-types: squamous cell carcinoma and adenocarcinoma. Approximately 6%-12% of adenocarcinomas have driver mutations for which targeted biological systemic therapies are available. Many patients may be suitable for immunotherapy. The number of targeted treatments is likely to increase in the future. Immuno-genetic classification is important since it has significant implications for treatment (East Midlands Clinical Senate 2017).  

SCLC is generally a more aggressive tumour and more responsive to chemotherapy treatments. Symptoms often occur over a short period of time and urgent medical intervention is required.

Treatment

Lung cancer treatment is determined by stage, morphology, fitness and patient preference. For early stage disease in fit patients, surgical resection is the treatment recommended. For less fit patients with early stage disease, surgery is preferred but radical radiotherapy, especially Stereotactic Ablative Radiotherapy (SABR) is an option. The treatment of later stage disease can be with surgery, radiotherapy or chemo-radiotherapy.

The treatment of advanced NSCLC depends on the sub-type and also, for adenocarcinoma, on whether there is a sensitising mutation. The latter may influence both first and second line treatment options. There are a number of other palliative treatments that are used. These include palliative radiotherapy, for airwave obstruction, chest wall pain, metastases, cough control and haemoptysis. Also, endobronchial tumour treatment, pleural procedures, including fluid drainage, pleurodesis, indwelling pleural catheter, and supportive care, including a full holistic approach.

For SCLC, chemotherapy or chemo-radiotherapy is the recommended treatment. Treatment of SCLC depends on whether the tumour can be encompassed in a radiotherapy field, in which case concurrent chemo-radiotherapy is generally offered to fitter patients. The palliative treatments and supportive care also apply to people with SCLC.

Clinical trials and eligibility for trials is a major influence on treatment options and patients and carers need to be aware of this.

Nursing issues

Only 30% of people diagnosed with lung cancer survive one year, and during this time they may have distressing symptoms, especially towards the end of life. Treatment for advanced disease causes significant side effects and people are often older with multiple co-morbidities. There is evidence that early supportive care and continuity of care results in improved quality of life measures and for this to be correctly targeted there needs to be early and regular assessment of needs (Temel J et al 2010, Ferrell B et al 2017).

The lung cancer nurse specialist (LCNS) is best placed to provide the essential holistic and supportive care, as well as an expert view of the individual’s position on the pathway from pre-diagnosis to end of treatment. The LCNS will have a close working relationship with specialist palliative care services that are often required to meet the needs of patients.

Essential facts covering the consequences of lung cancer

Lung cancer carries significant symptomatic burden and patients with metastatic disease experience clinically significant levels of fatigue, cachexia, dyspnoea and psychological distress, such as anxiety and depression.

These symptoms may also be related to concurrent treatments such as radiotherapy, chemotherapy and medications. Patients who have high levels of unmet symptom needs are associated with poorer physical and psychological functioning.

Cancer rehabilitation aims to maximise patients’ functional independence, facilitate adaptation to a changing health status and improve quality of life.

The National Institute for Health and Care Excellence (NICE) recommends that all cancer patients have their rehabilitation needs assessed through an active and planned approach to rehabilitation that enables access to services without undue delay (NICE 2004).

Rehabilitation is an important aspect of supportive care that should involve an agreed recovery package and include:

  • Pulmonary rehabilitation delivered pre- and/or post treatment.
  • Structured holistic needs assessment and care planning.
  • Treatment summaries.
  • Patient education and support events (health and well-being clinics).
  • The provision of advice, and access to schemes, to support people to undertake physical activity and healthy weight management.
  • Nutritional interventions for people at high risk of malnutrition.

The aim of the lung cancer service is to deliver high quality holistic care for patients with lung cancer to increase survival while maximising a patient’s functional capability and quality of life.  It also aims to ensure ready and timely access to appropriate supportive care for patients, their relatives and carers. Excellence in outcomes, enabling people to live with and beyond lung cancer is dependent on factors crossing health sector boundaries.
These include:

  • A pro-active approach to prevention through smoking cessation.
  • Awareness of the early symptoms and the benefits of making an early diagnosis within the general population.
  • A high level of awareness and prompt attention to warning symptoms in primary care.
  • Access to expert diagnostic and specialist treatment services.
  • Services must ensure that people have the same access to care that improves all aspects of living with and beyond cancer.

Expert view

Josie Roberts, Macmillan lung nurse specialist, the Rotherham NHS Foundation Trust, South Yorkshire

In recent years, there have been important developments in the techniques used to diagnose lung cancer and in the treatments options available, allowing more people to be given anti-cancer treatment with the aim of increasing survival rates.

Although survival and quality of life are significantly affected by lung cancer, new diagnostic, surgical and oncological treatments are being introduced, giving more patients the opportunity to be treated with potentially curative therapies.

The diagnosis and treatment of lung cancer have a wide spectrum of supportive care needs for patients and their carers (Maguire et al 2013). These include physical, daily living, psychological, emotional and spiritual, informational, practical, communication, social and family related and cognitive needs, which clearly demonstrates the significant burden and challenges facing people with lung cancer.

Offering a holistic needs assessment can help identify concerns and lead to timely and appropriate support to enhance quality of life.

Pulmonary rehabilitation has an established role within the management of patients with chronic obstructive pulmonary disease (COPD) with significant improvement in exercise capacity, quality of life and symptoms and reduction in hospital admissions. 

Evidence to extend this to improve exercise capacity for patients following surgery for lung cancer (Coups et al 2009) is ongoing. Offering a health and well-being event is also strongly advocated (Elliott et al 2011).

Living with and beyond lung cancer needs to include the physical and psychological issues for patients diagnosed with a life threatening disease and an increased symptom burden which often affects people with existing medical conditions and co-morbidities.


References

  • Calman L, Beaver K, Hind D et al (2011) Survival benefits from follow-up of patients with lung cancer: a systematic review and meta-analysis. Journal of Thoracic Oncology. 6, 12, 1993-2004.
  • Cancer Research UK, Lung cancer (2013)-UK incidence statistics. Q3 this link does not work, please insert correct one. info.cancerresearchuk.org/cancerstats/types/lung/incidence  
  • Coups E, Park B, Feinstein M et al (2009) Physical activity among lung cancer survivors: changes across the cancer trajectory and associations with quality of life. Cancer Epidemiology,  Biomarkers & Prevention. 18, 2, 664-672.
  • East Midlands Clinical Senate (2017) Q4 please check this reference emsenate.nhs.uk/downloads/documents/Lung_Pathway_-_Lung_Specification.pdf 
  • Elliott J, Fallows A, Staetsky L et al (2011) The health and well-being of cancer survivors in the UK: findings from a population-based survey. British Journal of Cancer. 105, Suppl 1, S11-S20. doi:  10.1038/bjc.2011.418.
  • Ferrell BR, Temel JS, Temin S et al (2017) Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology. 35, 1, 96-112.
  • National Institute for Health and Care Excellence (Q: date?) National Institute for Health and Care Excellence (20??) 
  • Maguire R, Papadopoulou C, Kotronoulas G et al (2013) A systematic review of supportive care needs of people living with lung cancer. European Journal of Oncology Nursing. 17, 4, 449-464.
  • McPhail S, Johnson S, Greenberg D at al (2015) Stage at diagnosis and early mortality from cancer in England. British Journal of Cancer. 112, Suppl 1, S108-S115.
  • National Institute for Health and Care Excellence (2004) Improving supportive and palliative care for adults with cancer. Cancer service guideline. National Institute for Health and Care Excellence (2004) 
  • NHS England (2015) Achieving world class cancer outcomes: a strategy for England 2015-2020. cancerresearchuk.org/about-us/cancer-strategy-in-england 
  • Temel JS, Greer JA, Muzikansky A et al (2010) Early palliative care for patients with metastatic non-small cell lung cancer. The New England Journal of Medicine. 363, 8, 733-42. DOI: 10.1056/NEJMoa1000678
  • Truong T, RJ Hung, CI Amos (2010) Replication of lung cancer susceptibility Loci at Chromosomes 15q25, 5p15, and 6p2: a pooled analysis from the international lung cancer consortium. Journal of the National Cancer Institute. 102, 13, 959-971.
  • United Kingdom Lung Cancer Coalition (2016) 25 by 25. A ten-year strategy to improve lung cancer survival rates. uklcc.org.uk/files/UKLCC-%2025%20by%2025%20FINAL.pdf  

 

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