Last updated March 14, 2022

Symptom Management In Patients With Lung Cancer: Diagnosis And Management Of Lung Cancer

Recommendations

Pain Control

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. (2, C)
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In patients with lung cancer who experience chronic pain, the use of the WHO analgesic ladder to plan treatment is suggested. (2, C)
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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 NSAID be prescribed unless contraindicated. (1, A)
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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 doubledose histamine H2 antagonists. (1, A)
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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. (1, A)
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In patients with chronic pain due to lung cancer, the use of ketamine, lidocaine 5% plasters, and cannabinoids is not recommended. (1, A)
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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. (1, C)
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In lung cancer patients with severe chronic pain, oral morphine is recommended as first-line treatment. (1, C)
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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. (1, A)
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In lung cancer patients with severe chronic pain due who are able to swallow, transdermal fentanyl is not recommended for firstline use. (1, C)
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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. (1, B)
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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. (2, C)
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In lung cancer patients with severe chronic cancer pain, treatment with systemic strong opioids is recommended. (1, C)
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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.

(1, C)
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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. (2, C)
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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. (2, B)
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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. (1, B)
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Dyspnea

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 QOL. (1, C)
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Palliation of Cough

In all lung cancer patients with troublesome cough, evaluation for other treatable causes of cough, in addition to cancer-related etiologies is recommended. (1, C)
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In all lung cancer patients with troublesome cough without a treatable cause, it is recommended that opioids be used to suppress the cough. (1, B)
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In all lung cancer patients with troublesome cough attributed to chemotherapy or radiationinduced pneumonitis, anti-inflammatory therapy with corticosteroids is recommended. (1, C)
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Palliation of Bone Metastases

In patients with lung cancer who have pain due to bone metastases, external radiation therapy is recommended for pain relief. (1, A)
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In patients with lung cancer who have painful bone metastases, bisphosphonates are recommended in addition to external beam radiation therapy for pain relief. (1, A)
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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. (1, C)
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In patients with lung cancer who have vertebral compression fractures causing pain, vertebral augmentation procedures are recommended to reduce pain. (1, A)
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Palliation of Brain Metastases

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. (1, B)
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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. (1, B)
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In lung cancer patients with 1 to 3 brain metastases, stereotactic radiosurgery (SRS) alone is the recommended initial therapy. (1, A)
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In patients with 5 or more brain metastases, whole brain radiation is the recommended therapy. (1, A)
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Palliation of Spinal Cord Compression

In patients with lung cancer that have new onset of back pain, sagittal T1-weighted MRI of the entire spine is recommended. (1, C)
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In patients with lung cancer and epidural spinal cord metastases, who are not symptomatic, prompt treatment with high-dose dexamethasone and radiotherapy is recommended. (1, B)
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In lung cancer patients with symptomatic radiographically confi rmed epidural SCC 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. (1, B)
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Palliation of SVC Obstruction

In patients with SVC obstruction from suspected lung cancer, definitive diagnosis by  histologic or cytologic methods is recommended before treatment is started. (1, C)
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In patients with symptomatic SVC obstruction due to SCLC, chemotherapy is recommended. (1, C)
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In patients with symptomatic SVC obstruction due to NSCLC, radiation therapy and/or stent insertion are recommended. (1, C)
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In patients with SCLC or NSCLC with SVC obstruction who fail to respond to chemotherapy or radiation therapy, vascular stents are recommended. (1, C)
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Management of Hemoptysis

In all lung cancer patients with large volume hemoptysis, securing the airway with a single-lumen endotracheal tube is recommended. Bronchoscopy is recommended to identify the source of bleeding, followed by endobronchial management options such as argon plasma coagulation, Nd:YAG laser, and electrocautery for visible central airway lesions. (1, C)
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In all lung cancer patients with nonlarge volume hemoptysis, bronchoscopy is recommended to identify the source of bleeding. For visible central airway lesions, endobronchial management options are recommended. For distal or parenchymal lesions, external beam radiotherapy (EBRT) is recommended.

(1, C)
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Management for Airway-Esophageal Fistulas

In patients with TEFs, double stenting of the esophagus and airway or esophageal stenting is recommended with self-expanding metallic stents. (1, B)
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Management of Malignant Pleural Effusions

In patients with a symptomatic recurrent MPE with documented re-expandable lung, TPCs or chemical pleurodesis are recommended. (1, C)
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In patients with a symptomatic recurrent MPE with lung trapping, tunneled catheters are recommended for symptomatic relief and improvement in QOL. (1, C)
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In lung cancer patients with a suspected MPE in whom the diagnosis of stage IV disease is not confirmed, thoracoscopy is recommended instead of a tunneled catheter due to its diagnostic as well as therapeutic benefit. (1, C)
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In patients with a MPE, graded talc is the pleural sclerosant that is recommended due to its efficacy and safety profile. (1, C)
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In lung cancer patients with a malignant effusion, thoracoscopy with talc poudrage is recommended instead of talc slurry through a bedside chest tube for pleurodesis (if there are no contraindications to thoracoscopy). (1, C)
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Management of Depression, Fatigue, Anorexia, and Insomnia

In patients recently diagnosed with lung cancer it is recommended that comprehensive biopsychosocial assessment be performed soon after the diagnosis is made and at key transition points (completion of treatment, disease progression, and new symptom onset) thereafter for the remainder of life. (1, C)
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In lung cancer patients that identify psychologic and physical symptoms causing distress or interfering with their QOL, it is recommended that these symptoms are addressed by appropriately trained individuals. (1, C)
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In lung cancer patients with depression, anxiety, excessive daytime sedation and fatigue, medications such as antidepressants, anxiolytics and psychostimulants are recommended to decrease the morbidity associated with these symptoms. (1, C)
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In lung cancer patients with psychologic symptoms, a comprehensive symptom management plan is recommended. This should include non-pharmacologic interventions integrated with medication management, which may be offered as a single treatment modality. (1, C)
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In lung cancer patients with insomnia, sedating antidepressants (which target both sleep and mood) are recommended over sedative-hypnotics (which only improve sleep). (1, C)
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In lung cancer patients with the subjective experience of breathlessness, interventions specifically designed to manage this symptom using psychologic coping and physical adaptation are recommended. (1, C)
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In lung cancer patients with psychologic distress, it is suggested that one of several psychologic interventions have demonstrated benefit (including psycho-education, deep breathing, progressive muscle relaxation, guided imagery,  cognitive behavioral therapy and supportive psychotherapy). (2, C)
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It is suggested that educational programs responsible for preparing health care professionals to care for persons with cancer should include specific training in psychologic and physical symptom management of symptoms frequently associated with cancer diagnosis, treatment and survivorship. (2, C)
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It is suggested that health care systems providing care to persons with cancer should develop and support integrated programs in psychologic and physical symptom management which are accessible to all. (2, C)
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Recommendation Grading

Overview

Title

Symptom Management In Patients With Lung Cancer: Diagnosis And Management Of Lung Cancer

Authoring Organization

Publication Month/Year

November 1, 2013

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

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.

Target Patient Population

Patients with lung cancer

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospice, Hospital, Long term care, Outpatient

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D000072716 - Cancer Pain, D010166 - Palliative Care, D065126 - Palliative Medicine, D008175 - Lung Neoplasms, D063189 - Symptom Assessment, D000073116 - Cancer Survivors, D001859 - Bone Neoplasms

Keywords

lung cancer, palliative care, bone metastases, palliation, cancer pain, airway management, symptoms