Superior sulcus (Pancoast) tumours


Guideline Developer(s)

CancerControl Alberta

Date Released

2012 Jan

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Implementation of the Guideline

Description of Implementation Strategy
  • Present the guideline at the local and provincial tumour team meetings and weekly rounds.
  • Post the guideline on the Alberta Health Services Web site.
  • Send an electronic notification of the new guideline to all members of Alberta Health Services, Cancer Care.
Implementation Tools

Clinical Algorithm

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate management of patients with superior sulcus (Pancoast) tumours

Potential Harms

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Qualifying Statements

Qualifying Statements

The recommendations contained in this guideline are a consensus of the Alberta Provincial Thoracic Tumour Team and are a synthesis of currently accepted approaches to management, derived from a review of relevant scientific literature. Clinicians applying these guidelines should, in consultation with the patient, use independent medical judgment in the context of individual clinical circumstances to direct care.

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Research Questions

Specific research questions to be addressed by the guideline document will be formulated by the guideline lead(s) and Knowledge Management (KM) Specialist using the PICO question format (patient or population, intervention, comparisons, outcomes).

Guideline Question

What are the recommended treatment options for patients with superior sulcus (Pancoast) tumours?

Search Strategy

For this guideline update, a search for new or updated practice guidelines published since September 2009 was conducted by accessing the websites of the following organizations: Cancer Care Ontario (CCO), British Columbia Cancer Agency (BCCA), Cancer Care Nova Scotia (CCNS), the National Comprehensive Cancer Network (NCCN), the Scottish Intercollegiate Guidelines Network (SIGN), the National Institute for Health and Clinical Excellence (NICE), the American College of Chest Physicians (ACCP), the Australian Cancer Network, and the European Society for Medical Oncology (ESMO).

Medical journal articles were searched using Medline Ovid (2009-2012), EMBASE (2009-2012), Cochrane Database of Systematic Reviews, and PubMed electronic databases; the references and bibliographies of articles identified through these searches were scanned for additional sources. The search terms included: Pancoast, Superior Sulcus, Lung Neoplasms [MeSH heading], Carcinoma, Non-Small Cell Lung [MeSH heading], practice guidelines, systematic reviews, meta-analyses, randomized controlled trials, and clinical trials. Articles were excluded from the final review if they: had a non-English abstract, were not available through the library system, were a case study involving less than 5 patients, or were published prior to January 2009.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Evidence was selected and reviewed by a working group comprised of members from the Alberta Provincial Thoracic Tumour Team and a Knowledge Management (KM) Specialist from the Guideline Utilization Resource Unit (GURU). A detailed description of the methodology followed during the guideline development process can be found in the Guideline Utilization Resource Unit Handbook (see the "Availability of Companion Documents" field).

Evidence Tables

Evidence tables containing the first author, year of publication, patient group/stage of disease, methodology, and main outcomes of interest are assembled using the studies identified in the literature search. Existing guidelines on the topic are assessed by the KM Specialist using portions of the Appraisal of Guidelines Research and Evaluation (AGREE) II instrument (http://www.agreetrust.org) and those meeting the minimum requirements are included in the evidence document. Due to limited resources, GURU does not regularly employ the use of multiple reviewers to rank the level of evidence; rather, the methodology portion of the evidence table contains the pertinent information required for the reader to judge for himself the quality of the studies.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Formulating Recommendations

The working group members formulate the guideline recommendations based on the evidence synthesized by the Knowledge Management (KM) Specialist during the planning process, blended with expert clinical interpretation of the evidence. As detailed in the Guideline Utilization Resource Unit Handbook (see the "Availability of Companion Documents" field), the working group members may decide to adopt the recommendations of another institution without any revisions, adapt the recommendations of another institution or institutions to better reflect local practices, or develop their own set of recommendations by adapting some, but not all, recommendations from different guidelines.

The degree to which a recommendation is based on expert opinion of the working group and/or the Provincial Tumour Team members is explicitly stated in the guideline recommendations. Similar to the American Society of Clinical Oncology (ASCO) methodology for formulating guideline recommendations, the Guideline Utilization Resource Unit (GURU) does not use formal rating schemes for describing the strength of the recommendations, but rather describes, in conventional and explicit language, the type and quality of the research and existing guidelines that were taken into consideration when formulating the recommendations.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Internal Peer Review

Description of Method of Guideline Validation

This guideline was reviewed and endorsed by the Alberta Provincial Thoracic Tumour Team.

When the draft guideline document is completed, revised, and reviewed by the Knowledge Management Specialist and the working group members, it is sent to all members of the Provincial Tumour Team for review and comment. The working group members then make final revisions to the document based on the received feedback, as appropriate. Once the guideline is finalized, it is officially endorsed by the Provincial Tumour Team Lead and the Executive Director of Provincial Tumour Programs.

Identifying Information and Availability

Bibliographic Source(s)

Alberta Provincial Thoracic Tumour Team. Superior sulcus (pancoast) tumours. Edmonton (Alberta): Alberta Health Services, Cancer Care; 2012 Jan. 8 p. (Clinical practice guideline; no. LU-005).  [13 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

Alberta Health Services, Cancer Care

Guideline Committee

Alberta Provincial Thoracic Tumour Team

Composition of Group That Authored the Guideline

Not stated

Financial Disclosures/Conflicts of Interest

Participation of members of the Alberta Provincial Thoracic Tumour Team in the development of this guideline has been voluntary and the authors have not been remunerated for their contributions. There was no direct industry involvement in the development or dissemination of this guideline. Alberta Health Services, Cancer Care recognizes that although industry support of research, education and other areas is necessary in order to advance patient care, such support may lead to potential conflicts of interest. Some members of the Alberta Provincial Thoracic Tumour Team are involved in research funded by industry or have other such potential conflicts of interest. However the developers of this guideline are satisfied it was developed in an unbiased manner.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Alberta Health Services Web site.

Availability of Companion Documents

The following is available:

  • Guideline utilization resource unit handbook. Edmonton (Alberta): Alberta Health Services, Cancer Care; 2011 Dec. 5 p. Electronic copies: Available in Portable Document Format (PDF) from the Alberta Health Services Web site.
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on December 13, 2012. The information was verified by the guideline developer on February 1, 2013. This summary was updated by ECRI Institute on July 18, 2014 following the U.S. Food and Drug Administration advisory on Docetaxel.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Scope

Disease/Condition(s)

Superior sulcus (Pancoast) tumours

Note: Superior sulcus tumours of the lung (T3-4, N0-1), often termed Pancoast tumours, occur in less than 5 percent of all non-small cell lung cancer cases.

Guideline Category

Management
Treatment

Clinical Specialty

Family Practice
Internal Medicine
Oncology
Pulmonary Medicine
Radiation Oncology
Surgery

Intended Users

Physicians

Guideline Objective(s)

To provide recommendations on management of superior sulcus (Pancoast) tumours

Target Population

Adult patients over the age of 18 years with superior sulcus (Pancoast) tumours

Interventions and Practices Considered
  1. Considering patients for eligibility in ongoing clinical trials
  2. Management of patients who are medically and surgically operable
    • Pre-operative chemo-radiation
    • Chemotherapy: cisplatin-etoposide
    • Surgery 3 to 7 weeks after the completion of chemo-radiation
  3. Boost radiation for patients in whom surgery is no longer an option after completing pre-operative chemo-radiation or in the case of positive margins
  4. Use of chemoradiation with curative intent for patients who are inoperable or who refuse surgery (cisplatin-based chemotherapy with either etoposide or vinorelbine and thoracic radiation)
  5. Palliative chemotherapy for management of inoperable patients
    • First line: platinum-based doublets
    • Second line: docetaxel, erlotinib or pemetrexed
  6. Palliative radiation therapy
Major Outcomes Considered
  • Complete resection
  • Pathologic complete response
  • Three- and five-year overall survival rates

Recommendations

Major Recommendations
  1. Whenever possible, patients should be considered for eligibility in ongoing clinical trials.

Operable

  1. If medically and surgically operable, patients should undergo pre-operative chemo-radiation.
    • Radiation dose: 45 Gy/25 fractions
    • Chemotherapy: cisplatin-etoposide (cisplatin 50 mg/m2 days 1, 8, 29, 36; etoposide 50 mg/m2 days 1 to 5 and 29 to 33)
    • To be followed by surgery 3 to 7 weeks after the completion of chemo-radiation.
  2. For patients in whom surgery is no longer an option after completing pre-operative chemo-radiation or in the case of positive margins, boost radiation is recommended.

Inoperable – Curative Intent

  1. For patients who are inoperable or who refuse surgery, chemo-radiation is recommended provided the patient can tolerate it.
    • Cisplatin-based chemotherapy (with either etoposide or vinorelbine) and thoracic radiation of 55 Gy/25 fractions to 66 Gy/33 fractions is the recommended treatment option.

Inoperable – Palliative

  1. In patients where lung reserve or effusion precludes radical radiotherapy, palliative chemotherapy and/or palliative radiotherapy are recommended.
  2. Palliative chemotherapy options include:
    • First line: platinum-based doublets
    • Second line: docetaxel, erlotinib or pemetrexed
  3. For symptomatic patients with poor performance status (Eastern Cooperative Oncology Group [ECOG] >2) and/or significant weight loss (usually defined as >10% in preceding 3 months), radiotherapy for symptom palliation is recommended.
    • Commonly used dose-fractionation schedules include 20 Gy/5 fractions and 30 Gy/10 fractions. Other dose-fractionation schedules may be used at the discretion of the radiation oncologist.
    • Single fractions of radiotherapy less than 10 Gy may be appropriate in some clinical circumstances, such as poor performance status or patient travel distance.
    • In selected cases, split course radiation can be used for palliation.
Clinical Algorithm(s)

A treatment algorithm is provided in the original guideline document.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

End of Life Care
Getting Better
Living with Illness

IOM Domain

Effectiveness

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