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National Guidelines for Lung Cancer Care and Treatment – summary

In total, the National Guidelines for Lung Cancer Care and Treatment 2011, comprehend 68 recommendations within the areas of diagnostics, surgery, radiation treatment, chemotherapy, palliative treatment and care.

The national guidelines for lung cancer care and treatment in Sweden illuminate those areas where the need for direction and guidance is greatest owing to differences in practice, unequal levels of care across the country or where controversial issues arise. Standard treatments and non-controversial measures are therefore not included in the guidelines. The starting point has been to look at the entire value chain but only to include those questions at issue where there is a great need for guidance.

Within the area of palliative treatment and care, the Swedish National Board of Health and Welfare has only included those measures specific to lung cancer. For overall palliative measures, reference is hereby made to the National Guidelines for Breast, Colorectal and Prostrate Cancer Medicine 2007. The National Board of Health and Welfare also has a mandate from the government to formulate a national knowledge support in the interests of good palliative care and treatment. This is expected to be ready in 2012. The guidelines for lung cancer treatment and care do not cover measures to get people to stop smoking. Measures to stop smoking are dealt with in the guidelines of the National Board of Health and Welfare concerning disease prevention methods, published in a preliminary version in October 2010.

Certain central recommendations and their consequences

The National Board of Health and Welfare adjudges that a number of recommendations within diagnostics, curative treatment and palliative treatment are those that have the greatest consequences in economic and organisational terms. This is because they demand changes in the organisation of Health and Medical Care as well as investments in human resources and competence. These central recommendations are no more important than other recommendations in the guideline but have been described in more detail here in Support for Guidance and Management (‘Stöd för styrning och ledning’) owing to their impact on the economics and organisation of Health and Medical Care in Sweden.

The assessments made by the National Board of Health and Welfare in respect of economic and organisational consequences should be seen as estimates made on the basis of the activities carried out today by each county council (landsting). After the preliminary version, this chapter has been supplemented with viewpoints from Sweden’s Health Care regions. All recommendations with justification for prioritisation and the underlying scientific data are to be found on the National Board of Health and Welfare website Nationella riktlinjer för lungcancervård.

PET-DT and multidisciplinary conference are amongst highly prioritised diagnostic measures

The National Board of Health and Welfare gives high priority to a number of new methods within lung cancer diagnostics, such as Positron Emission Tomography combined with computerised tomography (PET-DT), Endobronchial and Esophageal Ultrasound, immunohistochemical biomarkers as well as multidisciplinary conference.

PET-DT has different areas of application but, in general, the utilisation of PET-DT is expected to increase. At present, the utilisation of the existing PET-DT equipment varies widely. The National Board of Health and Welfare adjudges that a more extensive use of PETDT will increase the costs of diagnostics in the short term but that a more effective care and treatment and a reduced demand for other investigative methods will compensate the short-term cost increase, either partly or wholly.

Endobronchial and Esophageal Ultrasound should be used to map the lymph nodes in the area between the lungs (mediastinum). Used in combination, they reach more lymph nodes than the standard method used today i.e. Mediastinoscopy, and entail less discomfort and fewer risks. One disadvantage, however, is that the methods presuppose experienced diagnosticians and require a long time to learn. The need for training is estimated to be considerable throughout Sweden and, in the short term, investment is also required in equipment at a number of locations. The combination of these examination methods has a high priority although it is currently used to a very small extent across Sweden as a whole.

To further characterise which type of lung cancer a person has, or whether a metastasis from another cancer is concerned, it is possible to examine so-called immunohistochemical biomarkers in the tissue sample. In order to carry out the analyses a tissue sample is required that is sufficiently large and of good quality. The quality of the tissue sample and thereby the possibility of making supplementary analyses varies at present across the country.

The Multidisciplinary Conference contributes to persons with lung cancer being able to obtain more coherent information about their care and treatment as well as a correct assessment. There is a great variation in how the Multidisciplinary Cancer Conference is designed and how many people are invited to it today. The National Board of Health and Welfare assesses that the costs for the Multidisciplinary Conference will increase as a consequence of increased treatment intensity and owing to the initial investments. However, a faster decision on correct treatment can deliver savings through avoiding subsequently arising costs in the treatment of the lung cancer.

Stereotactic Radiation Therapy and radiochemotherapy are highly prioritised curative treatments

Stereotactic Radiation Therapy should be given to those persons with non-small cell lung cancer of stage 1 who cannot be operated owing to another illness that prevents, or make more problematic, an operation, e.g. cardiac disease or KOL. The treatment in this case requires less time than conventional radiotherapy and persons who receive stereotactic radiation therapy do not need to come to hospital as frequently. At the present time, all Swedish regions have the technology at their disposal. Nevertheless, the organisation is lacking to enable persons to be assessed and referred within and between the different regions. The costs of stereotactic radiation therapy will indeed be lower if the recommendation is implemented since the present treatment alternative for this patient group is more costly in overall terms.

Radiochemotherapy, a combination of cytostatic and radiotherapy, should be given to persons with locally advanced non-small cell lung cancer who cannot be operated on. The combination has a greater chance of being curative than radiotherapy alone. The recommendations entail somewhat higher costs for care beds and supporting medication.

Palliative radiotherapy, chemotherapy and other symptom alleviation are high priority palliative treatments

The National Board of Health and Welfare, in the guidelines for lung cancer, only include lung cancer specific palliative measures.

Health and Medical Care should provide palliative radiotherapy to those persons with incurable lung cancer with symptoms from the breast organ. The method is effective in alleviating symptoms and relatively low cost but it is underutilised throughout Sweden. The recommendation will result in a greater use of radiotherapy than today. Palliative radiotherapy is presumably cost saving since the alternative of cytostatic therapy is more expensive and sometimes less effective.

Palliative chemotherapy can contribute to alleviating the symptoms and prolonging the life of persons with far-advanced lung cancer but it also implies an increased risk for adverse effects. In the guidelines, the National Board of Health and Welfare discusses supplementary treatment with bevacizumab, erlotinib, gefitinib and pemetrexed in the case of non-small cell lung cancer, all of which are associated with moderate to very high costs per effect. The chemotherapy area is constantly developing towards new and more individually adapted treatments and therefore this area needs to be reviewed continuously. It is hard to assess the national consequences for palliative chemotherapy but it will probably entail an increased cost for Health and Medical Care. It is not clear at present how many persons in Sweden receive palliative chemotherapy.

Opiates should not be given via the inhalation route where respiratory distress is present. Instead, they should be administered via the mouth or as an injection for persons with lung cancer and respiratory difficulties in the final stages of life. The supply of oxygen does not alleviate respiratory distress where there is an oxygen saturation in the blood of more than 90 per cent and this consequently should not be offered. Health and Medical Care should regularly use a symptom checklist to estimate symptoms in persons with lung cancer. These measures have no major economic consequences for Health and Medical Care but make clear the need for the appropriate competence and an organisation that is able to offer suitable palliative treatment.