Clinical Commander

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onc.lung-cancer.core.v1

Non-small cell lung cancer (NSCLC)

oncologychronicadultoutpatientinpatient
Start encounter →Print handoutPRODUCTION

NSCLC dossier. Covers LDCT screening (USPSTF 2021), nodule management (Lung-RADS/Fleischner), TNM 8th ed staging, comprehensive molecular testing (EGFR/ALK/ROS1/BRAF/KRAS G12C/PD-L1), and 4-axis stage-stratified regimen (early/locally-advanced/metastatic-molecular/metastatic-IO). 2026-05-25 safety pass: seed manifest authored (prisma/seed/manifests/onc.lung-cancer.core.v1.ts); all 18 antineoplastic RxCUIs live-verified vs RxNav property.json (~17 prior codes were wrong/invalid — e.g. cisplatin had clonidine 2599, osimertinib had nonathymulin 1946823, pembrolizumab/atezolizumab/durvalumab/etoposide/pemetrexed/docetaxel and every TKI were wrong or invalid — all corrected); evidence PMIDs re-verified (replaced fabricated 27354476=Hodgkin-lymphoma with TNM-8th 26762738, and fixed mislabeled PACIFIC 30280635=KEYNOTE-407 → 30280658). 2026-05-26 lane-A: design_brief authored (src/lib/dossiers/_briefs/onc.lung-cancer.core.v1.md); central orchestrator re-verified all 6 evidence PMIDs (FLAURA 29151359, KEYNOTE-024 27718847, KEYNOTE-189 29658856, ADAURA 32955177, PACIFIC 30280658, TNM-8 26762738) and all 18 RxCUIs against PubMed/RxNav — clean; promoted SCAFFOLDED → PRODUCTION.

Entry points (4)

  • imaging
    Incidental or screening-detected lung nodule (NCCN 2024 NSCLC)
    lung_nodule
  • symptom
    Persistent cough >3 weeks, hemoptysis, weight loss (NCCN 2024 NSCLC)
    persistent_cough
  • problem_list
    Biopsy-confirmed NSCLC (NCCN 2024 NSCLC)
    confirmed_nsclc
  • demographic
    Age 50-80, >=20 pack-year smoking history for LDCT screening (USPSTF 2021)
    ldct_eligible

Required inputs (11)

  • agerequired
    demographic • used at FRAME
    Screening eligibility (USPSTF 2021), surgical candidacy, performance status assessment (NCCN 2024 NSCLC)
  • smoking_pack_yearsrequired
    history • used at FRAME
    LDCT screening criteria >=20 pack-years (USPSTF 2021)
  • spo2required
    vital • used at CONTEXT
    Baseline oxygenation; respiratory compromise assessment (NCCN 2024 NSCLC)
  • weightrequired
    vital • used at CONTEXT
    BSA for chemotherapy dosing (NCCN 2024 NSCLC)
  • ct_chestrequired
    imaging • used at INITIAL_WORKUP
    Nodule characterisation, staging (TNM 8th ed)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline before chemotherapy; cytopenias affect eligibility (NCCN 2024 NSCLC)
  • creatininerequired
    lab • used at TREATMENT
    Renal function for cisplatin vs carboplatin selection (NCCN 2024 NSCLC)
  • lftrequired
    lab • used at TREATMENT
    Hepatic function for chemotherapy dosing and immunotherapy monitoring (NCCN 2024 NSCLC)
  • ecog_psrequired
    history • used at CONTEXT
    Performance status drives treatment eligibility (NCCN 2024 NSCLC)
  • autoimmune_disease
    history • used at CONTEXT
    Relative contraindication to checkpoint inhibitors (NCCN 2024 NSCLC)
  • molecular_panel
    lab • used at BRANCHING_WORKUP
    EGFR/ALK/ROS1/BRAF/KRAS G12C/PD-L1 testing mandatory in advanced NSCLC (NCCN 2024 NSCLC)

12-phase flow (12)

  1. 1FRAME
    Determine scope: LDCT screening vs nodule workup vs confirmed NSCLC staging/treatment (NCCN 2024 NSCLC)
    inputs: age, smoking_pack_years
    advance: Clinical pathway identified: screening, nodule management, or confirmed NSCLC (NCCN 2024 NSCLC)
  2. 2ENTRY
    Capture trigger: screening-eligible, incidental nodule, symptomatic presentation, or known diagnosis (NCCN 2024 NSCLC)
    inputs: age, smoking_pack_years
    advance: Entry trigger documented (NCCN 2024 NSCLC)
  3. 3CONTEXT
    ECOG performance status, comorbidities (COPD, cardiac, autoimmune), prior thoracic surgery/radiation, weight/BSA (NCCN 2024 NSCLC)
    inputs: spo2, weight, ecog_ps, autoimmune_disease
    advance: Performance status and comorbidity profile established (NCCN 2024 NSCLC)
  4. 4RED_FLAGS
    SVC syndrome, massive hemoptysis, spinal cord compression, brain metastases with midline shift — emergent intervention (NCCN 2024 NSCLC)
    inputs: spo2
    advance: No oncologic emergencies or emergencies addressed (NCCN 2024 NSCLC)
  5. 5INITIAL_WORKUP
    CT chest with contrast, PET-CT for staging, brain MRI (stage II+), PFTs if surgical candidate, tissue biopsy (NCCN 2024 NSCLC)
    inputs: ct_chest, cbc
    actions: panel.cbc, panel.renal, imaging.ct_chest, imaging.pet_ct
    advance: Histology confirmed and baseline staging imaging complete (NCCN 2024 NSCLC)
  6. 6BRANCHING_WORKUP
    Molecular testing: next-gen sequencing for EGFR, ALK (FISH/IHC), ROS1, BRAF V600E, KRAS G12C, MET exon 14, RET, NTRK; PD-L1 TPS (22C3); liquid biopsy if tissue insufficient (NCCN 2024 NSCLC)
    inputs: molecular_panel
    actions: workup.lymphadenopathy_biopsy
    advance: Actionable driver identified or all tested negative; PD-L1 TPS documented (NCCN 2024 NSCLC)
  7. 7DIFFERENTIAL
    Histologic subtype (adenocarcinoma vs squamous vs large cell vs NOS); rule out SCLC, carcinoid, mesothelioma, metastatic disease to lung (NCCN 2024 NSCLC)
    advance: NSCLC subtype confirmed with immunohistochemistry (NCCN 2024 NSCLC)
  8. 8RISK_STRATIFICATION
    TNM 8th edition staging (I-IV); Lung-RADS for nodules; Fleischner for incidental nodules; surgical risk (cardiopulmonary exercise testing) (NCCN 2024 NSCLC)
    inputs: ct_chest
    advance: Clinical/pathologic stage assigned; surgical candidacy determined (NCCN 2024 NSCLC)
  9. 9TREATMENT
    Stage-stratified treatment: I-II surgical resection +/- adjuvant chemo +/- osimertinib (ADAURA); III concurrent chemoRT +/- durvalumab (PACIFIC); IV molecular-driven TKI or PD-L1-driven immunotherapy or chemoimmunotherapy (NCCN 2024 NSCLC)
    inputs: creatinine, lft, ecog_ps, molecular_panel
    advance: Treatment plan selected with molecular/PD-L1 match documented (NCCN 2024 NSCLC)
  10. 10DISPOSITION
    Outpatient for systemic therapy; inpatient for surgical resection, post-op complications, or oncologic emergencies (NCCN 2024 NSCLC)
    advance: Care setting and treatment initiation timeline established (NCCN 2024 NSCLC)
  11. 11MONITORING
    CT q3-6 months for 2 years then annually; PFTs post-surgery; molecular resistance testing at progression; irAE monitoring on immunotherapy (LFT, TSH, glucose q2-4 weeks) (NCCN 2024 NSCLC)
    inputs: ct_chest, lft
    actions: panel.cbc, panel.renal, imaging.ct_chest
    advance: Surveillance schedule documented with response assessment criteria (NCCN 2024 NSCLC)
  12. 12FOLLOWUP
    Survivorship care plan, smoking cessation, palliative care integration, advance care planning, clinical trial eligibility assessment at progression (NCCN 2024 NSCLC)
    advance: Survivorship or palliative care plan documented; next scan scheduled (NCCN 2024 NSCLC)