Lung cancer · House

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.

References

1.ESMO Clinical Practice Guidelines on Non-Small-Cell Lung Cancer (2023, Pocket 2024) and Small-Cell Lung Cancer (2021, Pocket 2024) (2024)