2013ACCP肺癌诊疗指南(第3版)更新

2013-05-14 Chest 医脉通

       美国胸科医师学会(ACCP)的新的指南建议:应为肺癌的高危患者提供筛查。       《Chest》杂志5月份的特别增刊发表了ACCP第3版循证肺癌指南——《肺癌的诊断与治疗第3版:美国胸科医师学会循证临床实践指南》。在本指南中,美国胸科医师学会(ACCP)建议向由

       美国胸科医师学会(ACCP)的新的指南建议:应为肺癌的高危患者提供筛查。
       《Chest》杂志5月份的特别增刊发表了ACCP第3版循证肺癌指南——《肺癌的诊断与治疗第3版:美国胸科医师学会循证临床实践指南》。在本指南中,美国胸科医师学会(ACCP)建议向由于年龄大和吸烟史而发生肺癌风险显著升高的患者提供小剂量计算机体层摄影(LDCT)扫描。
       这些建议基于对证明在有组织的项目中进行筛查时肺癌特异性死亡率降低的数据的系统回顾。这是对2007年发布的上一版指南(当时还没有上述证据)的明显变化。
       新指南涵盖了支持在该人群中筛查肺癌以及筛查可降低发生肺癌风险升高者肺癌死亡率的证据。它们还记录了过去5年烟草领域的进展,包括肺癌患者戒烟的益处。
       “我们的新肺癌指南考虑了该领域的多方面进展和新信息,提供了与肺癌预防、筛查、诊断、分期以及药物和外科治疗相关的综合与具体建议。”指南工作组主席W. Michael Alberts(医学博士,工商管理硕士,美国胸科医师学会会员)在一份声明中说。
       指南还强调了多学科、基于团队的护理对有效的肺癌治疗的重要性——基于集体知识的协作决策可提供综合性最高的以患者为中心的护理,Alberts博士(美国佛罗里达州坦帕市Moffitt癌症中心)补充说。
复杂的相互作用
       ACCP指南指出,肺癌筛查是“对个体风险和许多其他关键因素复杂的相互作用,包括如何实施和由团队解读LDCT扫描。”此外,必须适当平衡益处与肺癌、放射及观察到偶发结节带来的相关焦虑。
       他们的指南还呼吁建立登记(旨在辅助解决大量仍悬而未决的问题以及实施筛查将出现的问题)。另外,指南还要求确定质量衡量指标以优化益处并减少害处。
        “肺癌筛查为特定个体提供了潜在益处,但是并不能代替戒烟。”Frank Detterbeck(医学博士,美国胸科医师学会会员,美国康涅狄格州耶鲁大学,指南工作组副主席)说。“然而,筛查并非扫描,它是一个过程。”Detterbeck博士在一份声明中补充说,“关于筛查的教育是消除错误概念和被误导的恐惧的关键。指南包括可帮助患者及医师决策过程的建议。它提供了一种结构,可更明确地解释我们已知的和我们只能推测的。”
其他组织情况
       越来越多的学会与组织发表了更新指南,这些指南反应了支持在高危人群中进行筛查的证据。例如,美国癌症学会(ACS)今年年初发布了关于癌症筛查的更新指南,该指南的结论是,目前有足够数据支持在某些高危个体中用LDCT进行筛查。
       美国国家综合癌症网络(NCCN)在一套新指南中支持肺癌筛查,并且建议在肺癌高危特定患者中用LDCT。这套指南发布于2011年,这使得该网络成为首个根据所有证据进行这种全面回顾并且更新建议的组织。
指南相关的拓展阅读:

ACCP: Updated lung cancer guidelines
Lung cancer causes more deaths in the United States, 160,000 estimated in 2012, than the next three most common cancers, colon, breast, and prostate, combined.
More than 1.6 million people worldwide were newly diagnosed with lung cancer, comprising 13% of all new cancer diagnoses, and 1.4 million died of lung cancer, which was 18% of all cancer deaths in 2008. 
The American College of Chest Physicians released the Diagnosis and Management of Lung Cancer, 3rd ed: ACCP Evidence-Based Clinical Practice Guidelines on Tuesday.  The guidelines represent the culmination of a multiyear rigorous process involving over 100 multidisciplinary experts in the fields of pulmonology, critical care, thoracic surgery, medical and radiation oncology, pathology, integrative medicine, primary care, health-care research, guidelines methodology, and epidemiology. The ACCP guidelines summarize the state of the art in lung cancer in 24 chapters and 278 recommendations, covering the entire scope of the field.
The new lung cancer guidelines incorporate the many clinical and methodological advances and new research in the field, providing comprehensive and evidence-based recommendations related to prevention, screening, diagnosis, staging, and medical and surgical treatments. Since the 2nd edition, the science of guideline methodology has greatly advanced, increasing the rigor of the evidence review and assessment, and providing a structured process for the development and grading of recommendations. The guidelines also showcase the importance of multidisciplinary, team-based care when it comes to effective lung cancer treatment; collaborative decisions based on collective knowledge provide the most comprehensive patient-focused care.
■Screening. For individuals at elevated risk of developing lung cancer, the guidelines recommend offering low dose CT (LDCT) scanning to screen for lung cancer in the context of a structured, organized screening program.  The recommendation is based on a systematic review of the data, which shows an important reduction in deaths from lung cancer when screening is done in an organized program. This is a clear change from the prior edition of the guidelines released in 2007, when such evidence was not available.
Lung cancer screening is a complex interplay of an individual’s risk, how LDCT scanning is performed and interpreted, and how findings are managed. Guidance is provided for follow-up of these nodules based on size and many other factors. The guidelines call for the establishment of a registry designed to help address the large number of unanswered questions that arise as screening is implemented. Additionally, the guidelines call for establishment of quality metrics so that benefits are optimized and harms are minimized.
■Advances in treatment. Treatment of lung cancer is progressing rapidly, with significant advances in all modalities, including surgery, radiation chemotherapy, and palliative care.  Treatment procedures detailed in the guidelines include the importance of accurate definition of the stage and the benefits of minimally invasive surgery. Today, patients with limited lung function also have treatment options such as stereotactic body radiosurgery. Molecular-based targeted chemotherapy can also shut down the cellular engine driving a tumor’s growth as dramatically as flipping a switch. The guidelines also make clear that a sophisticated approach to symptom control and palliative care can markedly improve both quality and quantity of life for individuals with lung cancer.
The data presented in the guidelines also underscore the importance of an integrated collaborative team of individuals, each with lung cancer expertise within their own specialty.
■Treatment of tobacco use. An ounce of prevention is still best; and the science behind treatment of tobacco dependency has matured tremendously. This edition of the guidelines outlines how to select the right interventions for someone who smokes and improve the rate of successful abstinence from smoking.
Smoking is a difficult addiction to overcome; however, significant advances have increased our understanding of the physiological and biological changes that make this chronic medical condition so challenging. Today, we have multiple treatment options to help these patients.  The guidelines include a detailed summary of the scientific basis and management strategies for an up-to-date, sophisticated, and evidence-based treatment program for tobacco use.
■Symptom management and palliation. For patients with advanced lung cancer, a major concern is palliation—easing the severity of pain and symptoms. In the past, the approach to palliative care was largely empiric, but as summarized in the guidelines, a large body of research has led to the development of a formal evidence-based approach. Many tools are available that provide effective symptom management and end-of-life care. The data also demonstrate that early inclusion of a palliative care team in the management of advanced lung cancer can meaningfully improve the quality of life for the patient.
The guidelines also review the scientific literature that has emerged on complementary therapies and integrative medicine. This includes interventions such as acupuncture, nutrition, and mind-body therapies. The guidelines outline which treatments and situations are scientifically supported for integration with standard treatments for lung cancer.

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