Red Flags
- Massive haemoptysis (>200 mL/24 h or hypoxic compromise) — emergency bronchoscopy + interventional radiology; secure airway[1]
- Superior vena cava obstruction (face/arm swelling, headache, distended chest veins) — urgent radiotherapy or stenting; high-dose corticosteroid in lymphoma[1]
- Spinal cord compression (back pain, weakness, sphincter disturbance) — emergency MRI; high-dose corticosteroid; radiotherapy or surgery within 24 h[1]
- Tumour lysis syndrome with high-burden disease starting therapy — IV fluid, allopurinol or rasburicase, electrolyte monitoring; nephrology consult[1]
First-line treatment
Interventions
- Multidisciplinary tumour board for all[1]Thoracic surgical, medical, radiation oncology, pulmonology, pathology, radiology, palliative care; treatment driven by histology, molecular profile, stage, performance status
- Stage I–II NSCLC — curative surgery[1]Lobectomy with mediastinal lymph node sampling/dissection; sublobar resection (segmentectomy) for selected ≤2 cm peripheral; SABR for medically inoperable; adjuvant osimertinib (EGFR+) or atezolizumab (PD-L1 ≥1%) per stage
- Stage III NSCLC — concurrent chemoradiation + immunotherapy[1]Concurrent platinum-based chemoradiation followed by durvalumab consolidation × 1 year (PACIFIC); selected resectable IIIA undergo surgery + neoadjuvant chemoimmunotherapy (CheckMate 816)
- Stage IV NSCLC — driver mutation drives first-line[1]EGFR mutation: osimertinib. ALK: alectinib/lorlatinib. ROS1: entrectinib/repotrectinib. BRAF V600E: dabrafenib + trametinib. KRAS G12C: sotorasib/adagrasib (later line). MET, RET, NTRK, HER2 — targeted agents. PD-L1 ≥50% no driver: pembrolizumab. Chemoimmunotherapy otherwise
- SCLC management[1]Limited stage: concurrent platinum-etoposide + thoracic RT + prophylactic cranial irradiation. Extensive stage: platinum-etoposide + atezolizumab or durvalumab; consider PCI or active brain MRI surveillance
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Osimertinib[1] | Third-generation EGFR tyrosine kinase inhibitor | 80 mg PO once daily | — | First-line for EGFR exon 19 deletion or L858R; adjuvant in resected stage IB–IIIA EGFR+; CNS-active; QTc, ILD, cardiotoxicity monitoring |
| Pembrolizumab[1] | Anti-PD-1 monoclonal antibody | 200 mg IV every 3 weeks or 400 mg every 6 weeks × up to 2 years | — | Stage IV NSCLC with PD-L1 ≥50% as monotherapy; combine with chemotherapy regardless of PD-L1; immune-related adverse events (pneumonitis, colitis, endocrinopathies, hepatitis) |
| Cisplatin or carboplatin + pemetrexed (non-squamous)[1] | Platinum doublet chemotherapy | Cisplatin 75 mg/m² or carboplatin AUC 5–6 + pemetrexed 500 mg/m² IV every 3 weeks × 4–6 cycles, then maintenance pemetrexed | — | Standard chemotherapy backbone for NSCLC non-squamous; folic acid + B12 with pemetrexed; renal dose adjustment for cisplatin |
| Carboplatin + paclitaxel (squamous NSCLC) or + pembrolizumab[1] | Platinum doublet ± immunotherapy | Carboplatin AUC 5–6 + paclitaxel 175–200 mg/m² IV every 3 weeks × 4 cycles, then pembrolizumab maintenance | — | Squamous NSCLC; combine with pembrolizumab regardless of PD-L1; hypersensitivity, neuropathy |
| Cisplatin/carboplatin + etoposide (SCLC)[1] | Platinum doublet chemotherapy | Cisplatin 60–80 mg/m² or carboplatin AUC 5 + etoposide 100 mg/m² IV days 1–3 every 3 weeks × 4 cycles | — | Standard chemotherapy backbone for SCLC; combine with atezolizumab or durvalumab in extensive stage; concurrent thoracic radiotherapy in limited stage |
Osimertinib[1]
Third-generation EGFR tyrosine kinase inhibitor
- Adult
- 80 mg PO once daily
- Paediatric
- —
First-line for EGFR exon 19 deletion or L858R; adjuvant in resected stage IB–IIIA EGFR+; CNS-active; QTc, ILD, cardiotoxicity monitoring
Pembrolizumab[1]
Anti-PD-1 monoclonal antibody
- Adult
- 200 mg IV every 3 weeks or 400 mg every 6 weeks × up to 2 years
- Paediatric
- —
Stage IV NSCLC with PD-L1 ≥50% as monotherapy; combine with chemotherapy regardless of PD-L1; immune-related adverse events (pneumonitis, colitis, endocrinopathies, hepatitis)
Cisplatin or carboplatin + pemetrexed (non-squamous)[1]
Platinum doublet chemotherapy
- Adult
- Cisplatin 75 mg/m² or carboplatin AUC 5–6 + pemetrexed 500 mg/m² IV every 3 weeks × 4–6 cycles, then maintenance pemetrexed
- Paediatric
- —
Standard chemotherapy backbone for NSCLC non-squamous; folic acid + B12 with pemetrexed; renal dose adjustment for cisplatin
Carboplatin + paclitaxel (squamous NSCLC) or + pembrolizumab[1]
Platinum doublet ± immunotherapy
- Adult
- Carboplatin AUC 5–6 + paclitaxel 175–200 mg/m² IV every 3 weeks × 4 cycles, then pembrolizumab maintenance
- Paediatric
- —
Squamous NSCLC; combine with pembrolizumab regardless of PD-L1; hypersensitivity, neuropathy
Cisplatin/carboplatin + etoposide (SCLC)[1]
Platinum doublet chemotherapy
- Adult
- Cisplatin 60–80 mg/m² or carboplatin AUC 5 + etoposide 100 mg/m² IV days 1–3 every 3 weeks × 4 cycles
- Paediatric
- —
Standard chemotherapy backbone for SCLC; combine with atezolizumab or durvalumab in extensive stage; concurrent thoracic radiotherapy in limited stage
Safety-net
- Smoking cessation at any stage of cancer treatment improves outcomes — utilise NRT, varenicline, behavioural support; do not use vaping as substitute[1]
- On immunotherapy: any new symptom (rash, diarrhoea, breathlessness, jaundice, headache, fatigue) — same-day medical review (immune-related adverse event)[1]
- Palliative care should be integrated early — improves symptom control, mood, and even survival in metastatic NSCLC[1]
Referral criteria
- Suspected lung cancer (haemoptysis, weight loss, persistent cough ≥3 weeks, mass on imaging)Rapid lung cancer pathway with thoracic oncology and imaging[1]
- Confirmed lung cancerMultidisciplinary thoracic oncology team[1]
- Oncological emergency (SVCO, spinal cord compression, tumour lysis, brain metastasis with raised ICP)Emergency department; oncology and relevant subspecialty[1]
- Eligible for low-dose CT screeningPulmonology / NCD clinic with imaging access[1]
Clinical summary
Diagnosis, biomarker-driven treatment of NSCLC and SCLC, immunotherapy, and palliative care for adults with lung cancer.