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Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Online Only Articles |

Symptom Management in Patients With Lung CancerSymptom Management: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines FREE TO VIEW

Michael J. Simoff, MD, FCCP; Brian Lally, MD; Mark G. Slade, MBBS, FCCP; Wendy G. Goldberg, MSN, APRN, BC; Pyng Lee, MD, FCCP; Gaetane C. Michaud, MD, FCCP; Momen M. Wahidi, MD, MBA, FCCP; Mohit Chawla, MD, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Dr Simoff), the Henry Ford Hospital, Detroit MI; the Department of Radiation Oncology (Dr Lally), University of Miami, Miami, FL; the Oxford Center for Respiratory Medicine (Dr Slade), Oxford, England; the Henry Ford Health System (Ms Goldberg), Consultation-Liaison Psychiatry and Josephine Ford Cancer Institute, Detroit, MI; the Department of Medicine (Dr Lee), National University Hospital, Singapore, Singapore; the Yale School of Medicine (Dr Michaud), Winchester Chest Clinic, New Haven, CT; the Duke University Medical Center (Dr Wahidi), Durham, NC; and the Memorial Sloan-Kettering Cancer Center (Dr Chawla), New York, NY.

Correspondence to: Michael Simoff, MD, FCCP, Pulmonary and Critical Care Medicine, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202; e-mail: msimoff1@hfhs.org


Funding/Sponsors: The overall process for the development of these guidelines, including matters pertaining to funding and conflicts of interest, are described in the methodology article.1 The development of this guideline was supported primarily by the American College of Chest Physicians. The lung cancer guidelines conference was supported in part by a grant from the Lung Cancer Research Foundation. The publication and dissemination of the guidelines was supported in part by a 2009 independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc

COI Grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.

Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://dx.doi.org/10.1378/chest.1435S1.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(5_suppl):e455S-e497S. doi:10.1378/chest.12-2366
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Background:  Many patients with lung cancer will develop symptoms related to their disease process or the treatment they are receiving. These symptoms can be as debilitating as the disease progression itself. To many physicians these problems can be the most difficult to manage.

Methods:  A detailed review of the literature using strict methodologic review of article quality was used in the development of this article. MEDLINE literature reviews, in addition to Cochrane reviews and other databases, were used for this review. The resulting article lists were then reviewed by experts in each area for quality and finally interpreted for content.

Results:  We have developed recommendations for the management of many of the symptom complexes that patients with lung cancer may experience: pain, dyspnea, airway obstruction, cough, bone metastasis, brain metastasis, spinal cord metastasis, superior vena cava syndrome, hemoptysis, tracheoesophageal fistula, pleural effusions, venous thromboembolic disease, depression, fatigue, anorexia, and insomnia. Some areas, such as dyspnea, are covered in considerable detail in previously created high-quality evidence-based guidelines and are identified as excellent sources of reference. The goal of this guideline is to provide the reader recommendations based on evidence supported by scientific study.

Conclusions:  Improved understanding and recognition of cancer-related symptoms can improve management strategies, patient compliance, and quality of life for all patients with lung cancer.

Figures in this Article
Pain Control

2.13.1. In patients with lung cancer who experience chronic pain, it is suggested that thorough assessment of the patient and his or her pain should be performed (Grade 2C).

Remark: A patient-reported pain scale should be the principal tool to assess their pain.

Remark: Visual analog scales (VASs), numerical rating scales (NRSs) and verbal rating scales are also suggested tools for rating pain.

2.13.2. In patients with lung cancer who experience chronic pain, the use of the World Health Organization (WHO) analgesic ladder to plan treatment is suggested (Grade 2C).

2.13.3. In patients with lung cancer who are being treated at all stages of the WHO analgesic ladder, it is recommended that acetaminophen and/or a nonsteroidal antiinflammatory drug (NSAID) be prescribed unless contraindicated (Grade 1A).

2.13.4. In lung cancer patients with chronic pain who are taking NSAIDs and who are at high risk of gastrointestinal bleeding it is recommended that they take either misoprostol 800 mcg/day, standard dose proton pump inhibitors, or double-dose histamine H2 antagonists (Grade 1A).

2.13.5. In patients with chronic neuropathic pain due to cancer, treatment with an anticonvulsant (eg, pregabalin, gabapentin or carbamazepine) or a tricyclic antidepressant (eg, amitriptyline or imipramine) is recommended (Grade 1A).

2.13.6. In patients with chronic pain due to lung cancer, the use of ketamine, lidocaine 5% plasters, and cannabinoids is not recommended (Grade 1A).

2.13.7. In lung cancer patients with mild to moderate chronic pain (score 3-6 on a VAS or NRS), it is recommended that codeine or dihydrocodeine be added to acetaminophen and/or NSAID (Grade 1C).

2.13.8. In lung cancer patients with severe chronic pain, oral morphine is recommended as first-line treatment (Grade 1C).

2.13.9. In lung cancer patients with severe chronic pain, oxycodone or hydromorphone are recommended as alternatives when there are significant side effects or lack of efficacy with oral morphine (Grade 1A).

2.13.10. In lung cancer patients with severe chronic pain who are able to swallow, transdermal fentanyl is not recommended for first-line use (Grade 1C).

2.13.11. In lung cancer patients with stable, severe, chronic cancer pain who have difficulty swallowing, nausea and vomiting, or other adverse effect from oral medications, transdermal fentanyl is recommended as an alternative to oral morphine (Grade 1B).

2.13.12. In lung cancer patients with severe chronic pain, it is suggested that the prescription of methadone as an alternative to oral morphine be confined to a specialist in palliative care units with experience in methadone prescription, because of difficulties with dose prediction, adjustment, and drug accumulation (Grade 2C).

2.13.13. In lung cancer patients with severe chronic cancer pain, treatment with systemic strong opioids is recommended (Grade 1C).

Remark: The oral route of administration is recommended on the grounds of convenience and cost.

2.13.14. In lung cancer patients with severe chronic cancer pain treated with systemic strong opioids who cannot swallow or who suffer excessive nausea and vomiting, the parenteral, transcutaneous or transmucosal route of administration is recommended (Grade 1C).

2.13.15. In the management of pain in lung cancer patients unable to take oral opioids, it is suggested that the subcutaneous route to administer continuous infusion of strong opioids, is equally effective as the intravenous route (Grade 2C).

2.13.16. In lung cancer patients with severe chronic cancer pain treated with systemic strong opioids, dose titration using either immediate release or sustained release oral morphine is suggested (Grade 2B).

Remark: The recommended starting dose is oral morphine 30 mg/24 h in patients not previously treated with opioids, and 60 mg/24 h in those already taking an opioid at step 2 of the WHO ladder. Where immediate release oral morphine is used, the four-hourly dose is used to treat episodes of uncontrolled pain and in this context may be used up to hourly. The total dose administered in 24 h is used to calculate ongoing opioid requirements. Where sustained release morphine is used, the total estimated daily dose is prescribed as once-daily or twice-daily oral morphine.

2.13.17. In lung cancer patients with severe chronic cancer pain treated with systemic strong opioids who experience breakthrough pain, parenteral morphine or transmucosal fentanyl citrate are recommended (Grade 1B).

Remark: Oral transmucosal fentanyl citrate, fentanyl buccal tablet and transnasal fentanyl spray are all effective formulations for breakthrough pain.

Remark: In patients with severe chronic cancer pain who experience a lack of effective analgesia, or uncontrollable side effects, or both, it is appropriate to switch to an alternative strong opioid, or route of administration, or both, though evidence of benefit from this approach is lacking.

Airway Obstruction

4.1.1. In lung cancer patients with inoperable disease and symptomatic airway obstruction, therapeutic bronchoscopy employing mechanical debridement, brachytherapy, tumor ablation or airway stent placement is recommended for improvement in dyspnea, cough, hemoptysis and overall quality of life(QOL) (Grade 1C).

Symptom Management for Cough

5.4.1. In all lung cancer patients with troublesome cough, evaluation for other treatable causes of cough in addition to cancer-related etiologies is recommended (Grade 1C).

5.4.2. In all lung cancer patients with troublesome cough without a treatable cause, it is recommended that opioids be used to suppress the cough (Grade 1B).

5.4.3. In all lung cancer patients with troublesome cough attributed to chemotherapy or radiation-induced pneumonitis, anti-inflammatory therapy with corticosteroids is recommended (Grade 1C).

Remark: Macrolides can be considered as steroid-sparing agents.

Palliation of Bone Metastasis

6.7.1. In patients with lung cancer who have pain due to bone metastases, external radiation therapy is recommended for pain relief (Grade 1A).

Remark: A single fraction of 8 Gy is equally effective for immediate relief of pain and more cost-effective than higher fractionated doses of external radiation therapy.

6.7.2. In patients with lung cancer who have painful bone metastases, bisphosphonates are recommended in addition to external beam radiation therapy for pain relief (Grade 1A).

6.7.3. In patients with lung cancer who have painful bone metastases to long and/or weight bearing bones and a solitary well-defined lytic lesion circumferentially involving > 50% of the cortex and an expected survival > 4 weeks with satisfactory health status, surgical fixation is recommended to minimize the potential for a fracture (Grade 1C).

Remark: Intramedullary nailing is the preferred approach, especially for the femur or the humerus.

Remark: Radiotherapy should follow the orthopedic management 2-4 weeks later.

6.7.4. In patients with lung cancer who have vertebral compression fractures causing pain, vertebral augmentation procedures are recommended to reduce pain (Grade 1A).

Palliation of Brain Metastasis

7.6.1. In patients with lung cancer who have symptomatic brain metastases, dexamethasone at 16 mg/day is recommended during the course of definitive therapy with a rapid taper as allowed by neurologic symptoms (Grade 1B).

7.6.2. In lung cancer patients with significant brain edema, neurologic symptoms, or large space occupying brain metastasis (> 3 cm), surgical resection is recommended if they are surgical candidates (Grade1B).

7.6.3. In lung cancer patients with 1 to 3 brain metastases, stereotactic radiosurgery alone is the recommended initial therapy (Grade 1A).

Remark: With a low burden of disease, the benefit gained by delaying whole brain radiation therapy outweighs the potential risk.

7.6.4. In patients with 5 or more brain metastases, whole brain radiation is the recommended therapy (Grade 1A).

Palliation of Spinal Cord Compression

8.4.1. In patients with lung cancer that have new onset of back pain, sagittal T1-weighted MRI of the entire spine is recommended (Grade 1C).

8.4.2. In patients with lung cancer and epidural spinal cord metastases, who are not symptomatic, prompt treatment with high-dose dexamethasone and radiotherapy is recommended (Grade 1B).

8.4.3. In lung cancer patients with symptomatic, radiographically confirmed epidural spinal cord compression and good performance status, it is recommended that neurosurgical consultation be sought and, if appropriate, surgery should be performed immediately and followed by radiation therapy (Grade 1B).

Palliation of Superior Vena Cava Syndrome

9.1.1. In patients with superior vena cava (SVC) obstruction from suspected lung cancer, definitive diagnosis by histologic or cytologic methods is recommended before treatment is started (Grade 1C).

9.1.2. In patients with symptomatic SVC obstruction due to small cell lung cancer (SCLC), chemotherapy is recommended (Grade 1C).

9.1.3. In patients with symptomatic SVC obstruction due to non-small cell lung cancer (NSCLC), radiation therapy and /or stent insertion are recommended (Grade 1C).

Remark: When using stenting for the management of SVC obstruction, consideration of necessary anticoagulation as it relates to future management of the patient must be considered.

9.1.4. In patients with SCLC or NSCLC with SVC obstruction who fail to respond to chemotherapy or radiation therapy, vascular stents are recommended (Grade 1C).