2013-05-14 Chest 医脉通
“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。
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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.