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* From the Pulmonary Division (Dr. Rubins), Minneapolis VA Medical Center, University of Minnesota, Minneapolis, MN; Pulmonary Cancer Detection and Prevention Program (Dr. Unger), Fox Chase Cancer Center, Philadelphia, PA; and Pulmonary, Critical Care and Respiratory Services (Dr. Colice), Washington Hospital Center, Washington, DC.
Correspondence to: Jeffrey B. Rubins, MD, Pulmonary 111N, One Veterans Dr, Minneapolis, MN 55417; e-mail: rubin004{at}umn.edu
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Abstract |
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 TOP Abstract IntroductionFollow-up of Complications...RecommendationIssues in Surveillance for...RecommendationRecommendationRecommendationSmoking CessationRecommendationSummarySUMMARY OF RECOMMENDATIONSReferences |
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Methods: Guidelines on lung cancer diagnosis and management published between 2002 and December 2005 were identified by a systematic review of the literature, and supplemental material appropriate to this topic was obtained by literature search of a computerized database (Medline) and review of the reference lists of relevant articles.
Results: Adequate follow-up by the specialist responsible for the curative intent therapy should be ensured to manage complications related to the curative intent therapy and should last at least 3 to 6 months. In addition, a surveillance program should be considered to detect recurrences of the primary lung cancer and/or development of a new primary lung cancer early enough to allow potentially curative retreatment. A standard surveillance program for these patients, coordinated by a multidisciplinary tumor board and overseen by the physician who diagnosed and initiated therapy for the original lung cancer, is recommended based on periodic visits with chest imaging studies and counseling patients on symptom recognition. Smoking cessation and, if indicated, facilitation in participation in special programs is recommended for all patients following curative intent therapy for lung cancer.
Conclusions: The current evidence favors follow-up of complications related to curative intent therapy, and a surveillance program at regular intervals with imaging and review of symptoms. Smoking cessation after curative intent therapy to prevent recurrence of lung cancer is strongly supported by the available evidence.
Key Words: lung cancer • metachronous tumors • recurrence • surveillance
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Introduction |
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TOPAbstractIntroductionFollow-up of Complications...RecommendationIssues in Surveillance for...RecommendationRecommendationRecommendationSmoking CessationRecommendationSummarySUMMARY OF RECOMMENDATIONSReferences |
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Two distinctly different issues should be taken into account when planning patient care following curative intent therapy for lung cancer. First, adequate follow-up should be ensured to manage complications related to the curative intent therapy itself. This should be a specialist-directed process. The thoracic surgeon should be responsible for managing complications related to any surgical procedures performed, as should the radiation oncologist and the medical oncologist for managing complications related to radiation therapy and chemotherapy, respectively. In most cases, this specialist-directed follow-up should be transient.
Second, a surveillance program should be considered to detect recurrences of the primary lung cancer and/or development of a new primary lung cancer early enough to allow potentially curative retreatment. Numerous guidelines have been published regarding the management of lung cancer. Several of these guidelines include recommendations for a posttreatment surveillance program. These recommendations will be summarized and compared. Available data on rates, patterns, and diagnostic tools for identifying recurrence of the primary lung cancer and/or development of a second primary lung cancer will be reviewed as the basis for recommendations on an ongoing surveillance program following curative intent therapy for lung cancer. Issues related to follow-up for palliative therapy of lung cancer will not be discussed (see section on Palliative Treatment).
To update the previous recommendations on the follow-up and surveillance of lung cancer patients following curative intent therapy,4 guidelines on lung cancer diagnosis and management published between 2002 and December 2005 were identified by a systematic review of the literature using search terms including "follow-up," "surveillance," "lung cancer," and "lung neoplasms" (see "Methodology for Lung Cancer Evidence Review and Guideline Development" chapter). Those guidelines including recommendations specific to the follow-up and surveillance of lung cancer after curative intent therapy were identified for inclusion in this section. Supplemental material appropriate to this topic was obtained by literature search of a computerized database (Medline) and review of the reference lists of relevant articles. Recommendations were developed by the section editor and writing committee, graded by a standardized method (see "Methodology for Lung Cancer Evidence Review and Guideline Development" chapter), and then reviewed by all section editors, the Executive Committee of the panel, and then further reviewed by the Thoracic Oncology Network, Health and Science Policy Committee, and Board of Reagents of the American College of Chest Physicians (ACCP).
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Follow-up of Complications Related to the Original Mode of Curative Intent Therapy |
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TOPAbstractIntroductionFollow-up of Complications...RecommendationIssues in Surveillance for...RecommendationRecommendationRecommendationSmoking CessationRecommendationSummarySUMMARY OF RECOMMENDATIONSReferences |
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Unusual complications related to pulmonary resection may occur after hospital discharge. Case series1415 from the 1960s reported that persistent air in the pleural space was noted for weeks to months following lobectomy and pneumonectomy but usually resolved without complications. An autopsy series16 from the same time period confirmed residual air in the pleural space after pneumonectomy in 27 of 37 cases, even though surgery had been performed years before. In very rare situations, empyema may develop in these spaces.14 Torsion of the mediastinum developing after pneumonectomy may lead to mainstem bronchus obstruction.17
Complications of radiation therapy with curative intent for lung cancer include acute radiation pneumonitis and radiation-induced pulmonary fibrosis, as well as injury to the skin, heart, pericardium, esophagus, and spinal cord. Pulmonary radiation toxicity is related to the volume of lung irradiated, the cumulative dose effects of radiation sensitizing agents, and undefined factors determining the biological predisposition of the patient. In a large study18 using high-dose radiation therapy, acute toxicity was seen in 11% of the patients, with most injury relating to esophageal problems and only a third to lung toxicity. Acute radiation pneumonitis usually occurs within 3 months of treatment and is associated with nonproductive cough, dyspnea, and fever.19 It may resolve without treatment, but severe cases may be responsive to corticosteroid therapy. Inoue et al20 reported that 94 of 191 evaluable patients (49%) had acute radiation pneumonitis after thoracic radiotherapy for lung cancer, and 25 patients (13%) had severe cases. PaO2 < 80 mm Hg prior to radiotherapy may have indicated an increased risk for acute radiation pneumonitis in this study. Severe radiation pneumonitis was associated with poorer overall survival. Other work21 suggests that increased serum levels of KL-6 may be a useful marker of radiation pneumonitis. Radiation-induced fibrosis represents irreversible tissue damage, occurs in approximately 8% of patients treated with curative intent, and may present as early as 3 months and as late as 24 months after treatment.18 Even without producing overt pneumonitis, effective radiation therapy may result in a loss of pulmonary function. Miller et al22 described an average decrease in median FEV1, FVC, and diffusing capacity of the lung for carbon monoxide of 10% at 6 months after irradiation therapy, similar to that reported after lobectomy. All values were closer to baseline at 1 year after treatment but continued to decline by 7 to 10%/yr.22 However, Choi and Kanarek23 found that patients with poor lung function before treatment had little decrease in FEV1 after irradiation therapy.
Complications related to chemotherapeutic agents used for NSCLC and small cell lung cancer are usually detected during the course of therapy. A long-term morbidity of concern in patients who have completed chemotherapy is a mild-to-moderate peripheral neuropathy, which results from multiple treatments with the commonly used platin, vinca alkaloid, and taxane compounds. In addition, induction chemotherapy with cisplatinum and gemcitibine has been associated with a fall in diffusing capacity of the lung for carbon monoxide.24
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Issues in Surveillance for Recurrence of the Original Lung Cancer and Development of New Primary Lung Cancers |
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There is wide divergence among the guidelines regarding recommendations for chest imaging after curative intent therapy for lung cancer. The issues of radiographic detection of asymptomatic recurrent or metachronous cancer after treatment with curative intent are similar to those of early detection of primary cancer currently being investigated in high-risk patients (see section on "Screening for Lung Cancer"). Accordingly, the American Society of Clinical Oncology guidelines for NSCLC specifically state that there is no proven value for either chest radiograph (CXR) or CT in surveillance.26 However, the Association of Community Cancer Centers (ACCC) guidelines recommend routine CXR for surveillance.29 Guidelines from the American College of Radiology27 recommend a postresection chest CT scan to establish a new baseline and then annually in addition to interval CXR every 2 to 4 months. The most recent guidelines from the National Comprehensive Cancer Network (NCCN)28 rely entirely on chest CT scanning for surveillance imaging (Table 2).
With regards to other tests, the ACCC guidelines incorporate regular complete blood counts and serum chemistries into surveillance monitoring for NSCLC. Other groups found little value in performing these tests routinely for NSCLC, but these tests are recommended routinely in small cell lung cancer surveillance. Sputum cytology and various bronchoscopic techniques were specifically not incorporated into guidelines for surveillance practices.
Patterns of Recurrence
Numerous studies333435363738394041 have reported on recurrence rates and patterns in patients with NSCLC treated with curative intent surgical resection. In patients with stage I disease confirmed at surgery, 5-year recurrence rates 20 to 39% have been reported.343738 Most of these recurrences were distant metastases.343739 Although most recurrences were detected within the first 4 years following curative intent surgery,3738 recurrences may be discovered 
5 years following curative intent therapy.34373940 In patients with nodal involvement, recurrence rates increase353641 and recurrences probably occur earlier.333541
It has been estimated from published studies4243 on treatment outcomes that the approximate rate of a new primary lung cancer developing after curative intent therapy for a NSCLC is 1 to 2% per patient per year. Prospective lung cancer chemoprevention trials with vitamin A44 and isotretinoin45 also suggest similar rates for the development of metachronous tumors. In contrast, large population-based studies, such as the review of the regional cancer registry in Switzerland, suggest that in this population the rate may actually be slightly less than this estimate at approximately 0.5% per patient per year.46 However, this type of study may underestimate the incidence rate of metachronous tumors because of incomplete surveillance and misclassification of tumors as recurrences.45 Experience with long-term survivors of lung cancer indicate that new primary lung cancers may develop up to 20 years after the original cancer had been treated,47 but the available data are unclear on whether the rate of development of metachronous tumors increases or decreases over time.343943 An important point is that following curative intent therapy for NSCLC, patients are also at increased risk for other aerodigestive cancers (eg, carcinoma of the oropharynx and esophagus).4648
Roentgenographically occult lung cancers detected by sputum cytology have been reported to have an especially high rate of metachronous tumors. Saito et al49 described 13 metachronous tumors occurring in a group of 127 patients who underwent surgical resection for roentgenographically occult NSCLC. The cumulative rate at 5 years of metachronous tumors was 11%, and the incidence per patient year of surveillance was 2.2%. Bechtel and colleagues50 reported that seven metachronous tumors were identified in a group of 27 patients following surgical resection of a roentgenographically occult NSCLC. Consistent with these findings has been the observation that central lung cancers, treated with sleeve resection, may have a high rate of metachronous tumors approaching 7 to 8%.51
Patients treated for small cell lung cancer and surviving for 2 years have also been reported to have an especially high rate of metachronous NSCLCs developing. In two separate observational studies,52 NSCLC was diagnosed in 12 to 15% of patients surviving at least 2 years after therapy for small cell lung cancer (six cases in one group of 40 patients, and six cases in another group of 47 patients). It has been estimated that the rate of NSCLC developing 2 years after effective therapy for small lung cancer is 2 to 13% per patient per year.43 Another study53 confirmed that the rate of NSCLC developing following therapy for small cell lung cancer was significantly greater than expected from population data. A more recent study54 estimated that 10% of 2-year survivors of small cell lung cancer will eventually have NSCLC.
Curative Intent Therapy for Recurrence and/or New Primary
Most recurrences of lung cancer are found outside the thorax.33343536375253 Effective treatment of isolated metastases may be possible (see section on "Special Treatment Issues"). However, locoregional intrathoracic recurrences are only infrequently treated with curative intent surgical therapy,374055 and more often are treated with radiation therapy.5657 Regardless of therapy, the available data indicate that survival with locoregional recurrence of lung cancer appears to be poor.58
Although curative intent surgical therapy may be possibly more feasible with metachronous lung tumors than with locoregional recurrences of the primary lung cancer,47 patients with metachronous tumors often present with advanced stage disease or are unable to tolerate surgical resection due to pulmonary insufficiency.43 Limited data suggest that, even controlling for stage of disease, survival following curative intent surgical resection of metachronous lung tumors may not be as favorable as for the original lung cancer (Table 4 ). Despite limitations in the approach to curative intent therapy of metachronous lung cancers, 5-year survival rates of 25 to 53% (Table 4) have been reported when surgical resection is possible.
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In contrast, some case series616263 have reported that 68 to 100% of patients with metachronous lung cancers were asymptomatic and had the new primary lung cancer detected by radiographic methods. Lamont et al58 described a retrospective chart review of 124 patients following curative intent surgical resection of NSCLC. They had all been entered into a regular surveillance program, including a history, physical examination, and CXR at 4- to 6-month intervals and an annual CT. Of the 124 patients, metachronous lung cancers developed in 19 patients (15.3%; 2.1%/yr), and all 19 patients were asymptomatic at the time. Eleven of the 19 metachronous tumors were first detected by CT; 16 of the 19 patients had stage IA disease, and 14 patients underwent curative intent reoperation. Nine of 14 patients were alive without evidence of recurrent disease at a median of 20 months. These authors58 recommended annual CT for detecting metachronous tumors because disease can be identified early and resected, although the study was not designed to show a survival advantage for this group.
Other studies have provided an expanded view of the methods used for detecting recurrences and/or metachronous tumors by considering the costs involved in a surveillance program. Walsh et al64 retrospectively evaluated the course of 358 patients following curative intent surgical resection for NSCLC. There were 135 recurrences, and most (76%) were recognized through symptoms. Although the asymptomatic patients had a longer survival time following detection of the recurrence, the authors64 believed that this reflected lead-time bias and not a true survival benefit. Similar percentages of symptomatic (29%) and asymptomatic (30%) patients could be treated with curative intent. Seven metachronous lung cancers were recognized in this study, but information on therapy and survival for these patients was not provided. The authors64 concluded that intensive surveillance was not cost-effective and suggested a reduced surveillance approach consisting of a history, physical examination, and CXR every 6 months for the first year following curative intent surgery and then annually. Egermann and colleagues65 reached similar conclusions from their study of 563 patients who were cancer-free at 3 months following curative intent lobectomy for NSCLC. A history, physical examination, and CXR were performed at 3-month intervals for 2 years, and then at 6-month intervals for up to 5 years and then annually. Only 4.1% of the 361 patients had a potentially resectable lung cancer identified during follow-up. In 21 patients, metachronous tumors were detected and resected with curative intent. Survival analysis indicated a maximum survival benefit of 9 months; based on these data and estimated health-care costs in Switzerland, a calculated cost for the surveillance plan was $56,000 (US dollars) per life-year gained. The authors believed that this cost was too high to justify this intensive follow-up and recommended follow-up at 6-month intervals. A decision-analysis model approach to estimating the cost-effectiveness of chest CT in following patients after resection of stage 1A NSCLC arrived at a similar theoretical cost ($47,676 per quality-adjusted life-year gained).66 However, this analysis suggested that use of chest CT in surveillance might be cost-effective in patients < 65 years old; in clinical practices where the cost of chest CT was < $700, the annual incidence of second primary lung cancers was at least 1.6% per patient, and the false-positive rate of surveillance was < 14%.66
Virgo and colleagues67 compared two groups retrospectively following surgery for NSCLC. One group of 120 patients had intensive surveillance, consisting of at least four visits with serum chemistries and CXR per year, and annual bronchoscopy and/or sputum cytology with CT. The other group of 62 patients had less intensive surveillance, with on average only two visits with serum chemistries and CXR per year. No differences were found between the groups in either time to detection of recurrences or metachronous tumors or survival time. They agreed that intensive surveillance was not cost-effective and supported the surveillance schedule suggested by Walsh et al.64 Two other retrospective analyses of intensive surveillance methods provided similar results. Younes and colleagues68 found that intensive surveillance yielded no survival advantage and was more expensive than a symptom-based approach, although more patients in the symptom-based group had disease identified through emergency room visits. Gilbert and coworkers69 showed that more recurrences were found by family physicians based on symptomatic presentation than were identified through regularly scheduled surveillance visits to the surgical clinic. These investigators69 also found that the costs of identifying recurrences would be much lower using family physicians than intensive surveillance through the surgical clinic. Reviews7071 of this topic have endorsed the concept of less intense surveillance because "more intensive diagnostic testing has yet to demonstrate survival and quality of life benefits."70
The concept of less intensive surveillance has been challenged by work by Westeel et al,72 who instituted a very intensive surveillance program in 192 patients surviving 30 days after complete surgical resection for NSCLC. Visits were scheduled every 3 months for 3 years, with history, physical examination, and CXRs. Bronchoscopy and CT were performed at 6-month intervals. From the fourth year after surgery, visits with CXRs were at 6-month intervals, and CT and bronchoscopy were performed annually. At year 8, surveillance was reduced to a visit and CXR annually. They claimed good compliance with this surveillance regimen in a subset of the entire group. Of 136 patients with recurrent cancers, 35 cases (25.7%) were asymptomatic and detected by diagnostic procedures. Of these, 15 patients (11% of recurrences) had intrathoracic recurrences that could be treated with curative intent; these were diagnosed by CXR (n = 5), bronchoscopy (n = 5), or CT (n = 5). Survival after recurrence for the 36 patients with asymptomatic recurrences was significantly better than for the 100 patients with symptomatic recurrences. In their economic analysis, Westeel et al72 suggested that this very intensive surveillance regimen provided an acceptable cost per additional year of life gained. However, the improved survival, as measured after time of recurrence rather than after time of resection, in the asymptomatic patients may have reflected lead-time bias, and the proposed costs for procedures used in the surveillance strategy were relatively low.
Reconciling the conflicting findings from these various studies in order to provide clinical guidance is difficult. To begin, a clinically intuitive but often not stated principle is that patients who have a poor performance status or inadequate pulmonary function are not candidates for curative resection of either recurrent or metachronous lung cancer. Consequently, such patients are not candidates for intensive and aggressive surveillance programs designed to detect asymptomatic tumors. Instead, they should be educated to seek early attention and should have ready access to their providers for follow-up of new symptoms that might herald recurrent cancer. For patients with adequate performance status and lung function, the panel recognizes that periodic patient encounters following curative intent therapy for lung cancer are essential and strongly feels that imaging studies of the chest should be included in these visits. CT is accepted as more sensitive for detecting pulmonary nodules than CXR and has been shown to be more accurate for evaluating lung cancer response during chemotherapy.73 Small series597475 have shown that CT can detect changes consistent with recurrence earlier than CXR. CT is also being widely studied as a method for early detection of lung cancer (see "Screening for Lung Cancer" section). Unfortunately, the performance characteristics of CT (ie, sensitivity and specificity) for distinguishing nonspecific posttreatment changes related to surgery, radiation therapy, and/or chemotherapy from a recurrence and/or metachronous lung cancer have not been defined. Many studies58 report a high incidence of nodules in groups followed up with chest CT, and the appropriate protocols for differentiating benign from malignant nodules without excess morbidity and cost from diagnostic procedures have yet to be defined. Consequently, the panel was evenly divided between recommending CXR and CT as the imaging procedure of choice.
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Physician Factors Influencing Current Surveillance Methods
Numerous reports have evaluated individual factors that might influence the surveillance methods used by thoracic surgeons. These studies76 showed that many thoracic surgeons do perform regular surveillance for detecting recurrences and/or metachronous lung cancers following curative intent surgical therapy. The most commonly used methods were the history, physical examination, CXR, CBC count, and serum chemistries. Infrequently used surveillance methods were CT, bronchoscopy, sputum cytology, bone scan, and head CT. There was wide variation in the frequency at which these methods were used. This wide variation was probably due to the common belief that the clinical benefits of a surveillance program, particularly in terms of improving survival, had not been demonstrated. Interestingly, the age of the surgeon, the geographic region of practice, and the stage of the original lung cancer did not seem to influence the surveillance methods used by individual thoracic surgeons.777879 Motivating factors for continued surveillance seemed to be pleasing the patient, avoiding malpractice litigation, and potentially improving the patient’s quality of life.80 A more important issue, not specifically addressed in the surveys, was articulated by Shields81: "The least desirable course of action (in regard to care of the lung cancer patient following curative intent surgical therapy) is to pass the patient from one team member to another without continued surveillance by the primary responsible physician."
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Alternative Surveillance Techniques
There is considerable interest in developing noninvasive, easily performed, safe and accurate techniques for detecting recurrences and/or metachronous tumors at the earliest possible time. Positron emission tomography (PET) scanning is an established modality for identifying malignant pulmonary nodules, mediastinal nodal involvement in confirmed cases of lung cancer, and extrathoracic metastases (see sections on "Solitary Pulmonary Nodule" and "Noninvasive Staging"). As a metabolic imaging technique, PET may be able to distinguish recurrent cancer from the parenchymal scarring, distortion of bronchovascular anatomy, pleural thickening, and mediastinal fibrosis commonly seen on conventional imaging after initial treatment.82 Pooled data from studies to date indicate that PET has 96% sensitivity and 84% specificity for detecting recurrent lung cancer after treatment with surgery, chemotherapy, or radiotherapy.828384858687 The accuracy of PET has been dependent on the standardized uptake value used to define a positive test result, the delay between initial treatment and the PET scan, and the size of recurrent lesions and prevalence of bronchoalveolar cell carcinoma.84858788 Of note, the specificity of PET scan after definitive treatment is lower than at initial staging due to increased uptake on PET scan from inflammatory changes related to tumor necrosis and radiation pneumonitis.82 In addition, uptake on PET scans has been reported in the pleura of the shielded, nonirradiated lung even in the absence of overt radiation pneumonitis.89 It has been recommended that PET scans for evaluating recurrent disease not be performed after curative intent therapy for at least 3 to 6 months to minimize the possibility of false-positive findings, and that suspicious lesions on a surveillance PET scan be confirmed by CT imaging and biopsy.8290 Importantly, there are no data showing that incorporating PET scanning into a surveillance program improves either survival or quality of life following curative intent therapy for NSCLC.
Another approach to early identification of recurrences of lung cancer is based on measuring serum levels of tumor markers. Ichinose60 has recommended using serum carcinoembryonic antigen levels as a marker of tumor recurrence. Others9192 have also shown that elevated carcinoembryonic antigen levels following curative intent surgery for NSCLC may suggest recurrence. Other serum markers potentially useful for detecting tumor recurrence are levels of cytokeratin-19 fragments,93 serum amyloid A and macrophage migration inhibitory factor,94 and levels of pro–gastrin-releasing peptide in small cell lung cancer.95 Further studies will be needed to confirm the performance characteristics of tumor markers for identifying tumor recurrence.
Pilot studies9697 have been performed using fluorescence bronchoscopy to detect metachronous tumors after curative intent surgical resection of NSCLC. In a group of 73 patients who underwent fluorescence bronchoscopy at a median of 13 months following surgical resection, one invasive carcinoma and three cases of intraepithelial neoplasia were identified. The carcinoma was identified on routine white-light bronchoscopy, but fluorescence bronchoscopy was useful in identifying two of the three cases of intraepithelial neoplasia.96 In a smaller study97 of 25 patients studied on average about 20 months after curative intent surgery, fluorescence bronchoscopy was again found to be more sensitive that routine white-light bronchoscopy in detecting intraepithelial neoplasia. The impact of early detection of intraepithelial neoplasia on survival should be confirmed in larger studies before fluorescence bronchoscopy should be incorporated into surveillance programs.
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Smoking Cessation |
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Summary |
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5 years after surgery. Following curative intent therapy of lung cancer, the risk of a second primary, or metachronous, lung cancer developing may be 1 to 2% per patient per year lifelong. The risk for metachronous lung cancer may be even higher when the original primary is either roentgenographically occult, central, treated by sleeve resection only, or a small cell carcinoma. Curative intent therapy is less likely to be possible with locoregional recurrences of the original lung cancer than with metachronous tumors. Although survival is not as good with treatment of metachronous tumors as for the original primary, reasonable 5-year survival rates should be expected with surgical resection of metachronous lung cancers.
Benefits in terms of survival advantages or improvements in quality of life have not been demonstrated with intensive surveillance programs compared with either a symptom-based approach or a less intensive regimen. In addition, the intensive surveillance programs seem more expensive. A clinically reasonable and cost-effective surveillance approach would include a history, physical examination, and imaging study (either CXR or CT) every 6 months for 2 years and then annually, assuming no suspicious findings were seen. In addition, patients would be counseled on symptom recognition and be advised to contact the appropriate physician on symptom recognition. Further studies are needed to determine whether very intensive surveillance programs might be warranted in selected subsets of lung cancer patients: patients with roentgenographically occult primary lung cancers, and patients surviving > 2 years with small cell lung cancer and a complete response to original therapy, who have a very high expected rate of metachronous lung cancer.
Ideally, surveillance programs for recognition of a recurrence of the original lung cancer and/or development of a metachronous tumor following curative intent therapy should be coordinated through a multidisciplinary team approach. If possible, the physician who diagnosed the primary lung cancer and initiated the curative intent therapy should remain as the health-care provider overseeing the surveillance process. Patients with either a recurrence of their original cancer or a new primary lung cancer identified through the surveillance process should be reevaluated by the entire multidisciplinary team for potentially curative retreatment.
Although advanced imaging techniques, such as PET scanning, appear to be more sensitive than CXR for identifying recurrences and/or metachronous tumors, their value in improving either survival or quality of life following curative intent therapy for NSCLC is as of yet unproven. Incorporating PET scanning into a surveillance program should await the results of adequately designed and controlled, prospective trials. Similarly, serum levels of various tumor markers and fluorescence bronchoscopy should be demonstrated to be sensitive and specific predictors of tumor recurrence in adequately designed and controlled, prospective trials before being incorporated into surveillance programs.
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SUMMARY OF RECOMMENDATIONS |
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2. In lung cancer patients treated with curative intent therapy, and those having adequate performance and pulmonary functions, surveillance with a history, physical examination and imaging study (either CXR or CT) is recommended every 6 months for 2 years and then annually. All patients should be counseled on symptom recognition and be advised to contact their physician if worrisome symptoms were recognized. Grade of recommendation, 1C
3. Ideally, surveillance for recognition of a recurrence of the original lung cancer and/or development of a metachronous tumor should be coordinated through a multidisciplinary team approach. If possible, the physician who diagnosed the primary lung cancer and initiated the curative intent therapy should remain as the health-care provider overseeing the surveillance process. Grade of recommendation, 2C
4. In lung cancer patients following curative intent therapy, use of blood tests, PET scanning, sputum cytology, tumor markers, and fluorescence bronchoscopy is not currently recommended for surveillance. Grade of recommendation, 2C
5. Lung cancer patients who smoke should be strongly encouraged to stop smoking, and offered pharmacotherapeutic and behavioral therapy, including follow-up. Grade of recommendation, 1A
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The authors declare no personal, financial, or other potential conflicts of interest.
Received for publication May 30, 2007. Accepted for publication June 5, 2007.
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