Does routine follow-up improve patient outcomes in people who have curative intent treatments for lung cancer?

From Cancer Guidelines Wiki

Introduction

Routine clinical follow up following curative intent treatment is variably applied. There is variation in both the time intervals of follow up and the required investigations, with most guidelines recommending 3 monthly follow up for the first 2 years and 6 monthly to annually for the next 3 years. Clinical follow up is standard with chest imaging, including chest x-rays, CT scanning and occasionally PET scans.

The potential benefits include the early detection of recurrence or second primary cancer with the option for aggressive treatment resulting in a survival benefit. The surveillance programme can have significant cost implications.

The evidence for this is limited and is largely consensus and guideline driven and distinction needs to be made between small and non-small cell carcinoma. Westeel 2000, in a prospective, randomised controlled trial found that follow up was feasible and may improve survival. Three year survival was 31% if recurrence was found on follow up vs 4% if found on unscheduled visits. [1] Only 15 out of 136 recurrences could be treated with curative intent. A cost analysis showed a cost per life year gained of US$13415 which was felt to be feasible.[1] In a meta-analysis, Calman 2011 found no clear cut benefit to intensive follow up with a trend to improved survival favouring intensive follow up.[2]

Looking at small cell carcinoma, Sugiyama compared intensive (CXR, CT, MR/CT brain, bone scans bimonthly for 6 months and then quarterly for 18 months) with non-intensive follow up in patients with small cell cancer. Survival following recurrence was 9 months in the intensive group and 4 months in the non-intensive group (p = 0.001). Overall survival was also better, 20 vs 13 months (p = 0.04). Salvage treatment was possible in more of the patients undergoing intensive follow up and with better survival - 8 vs 1 month (p = 0.001).[3] Whilst the evidence on non-small cell carcinoma is not clear, there appears to be come survival benefit in small cell carcinoma.

In most studies, recurrences occurred more often within 2 years, justifying the intensive follow up in the first 2 years. Subsequent follow up investigations are mainly aimed at identifying new primaries. Subotic 2009, prospectively reported 88 patients treated surgically for NSCLC. This included 35(39.8%) patients with stage IIIA disease. They compared an intensive follow up consisting of monthly phone calls to the patient with standard follow up clinically. There was no increase in the detection of asymptomatic recurrence.[4]

Returning to the cost involved, a further cost analysis by Egermann 2002 found a cost per life year gained of 90000 Swiss Francs.[5] Goucerol 2013 demonstrated a survival benefit with asymptomatic recurrences of 15.5 months vs 7.2 months (p = 0.001 CI 1.33-3.28) and a cost per life year gained of USD32700.[6]

There are no local Australian guidelines for follow up and it is left to the discretion of the clinician to determine which guideline to follow.

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Evidence summary and recommendations

Evidence summary Level References
Routine follow up is feasible following curative intent treatment of lung cancer. IV [1]
Evidence-based recommendationQuestion mark transparent.png Grade
It is recommended that patients undergoing curative treatment for lung cancer have regular follow up.
D
Evidence summary Level References
Intensive follow up may improve survival following curative intent treatment for non-small cell carcinoma. III-2, IV [1], [2]
Evidence-based recommendationQuestion mark transparent.png Grade
It is recommended that patients undergo follow up after treatment for non-small cell carcinoma.
D



Practice pointQuestion mark transparent.png

It is advisable to utilise the many clinical guidelines available for follow up. There are no local Australian guidelines and the clinician may use the NICE guidelines.

Issues requiring more clinical research study

  1. What is the most appropriate time interval for surveillance in patients following curative intent treatment for lung cancer?
  2. What are the ideal follow up investigations following curative intent treatment for lung cancer?
  3. Is routine follow up cost-effective in an Australian setting?
  4. Should we be following up non-small and small-cell carcinoma with different protocols?
  5. Are there specific patient characteristics that predict improved survival during follow up for lung cancer?

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References

  1. 1.0 1.1 1.2 1.3 Westeel V, Choma D, Clément F, Woronoff-Lemsi MC, Pugin JF, Dubiez A, et al. Relevance of an intensive postoperative follow-up after surgery for non-small cell lung cancer. Ann Thorac Surg 2000 Oct;70(4):1185-90 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11081867.
  2. 2.0 2.1 Calman L, Beaver K, Hind D, Lorigan P, Roberts C, Lloyd-Jones M. Survival benefits from follow-up of patients with lung cancer: a systematic review and meta-analysis. J Thorac Oncol 2011 Dec;6(12):1993-2004 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21892108.
  3. Sugiyama T, Hirose T, Hosaka T, Kusumoto S, Nakashima M, Yamaoka T, et al. Effectiveness of intensive follow-up after response in patients with small cell lung cancer. Lung Cancer 2008 Feb;59(2):255-61 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17900754.
  4. Subotic D, Mandaric D, Radosavljevic G, Stojsic J, Gajic M, Ercegovac M. Relapse in resected lung cancer revisited: does intensified follow up really matter? A prospective study. World J Surg Oncol 2009 Nov 12;7:87 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19909550.
  5. Egermann U, Jaeggi K, Habicht JM, Perruchoud AP, Dalquen P, Solèr M. Regular follow-up after curative resection of nonsmall cell lung cancer: a real benefit for patients? Eur Respir J 2002 Mar;19(3):464-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11936523.
  6. Gourcerol D, Scherpereel A, Debeugny S, Porte H, Cortot AB, Lafitte JJ. Relevance of an extensive follow-up after surgery for nonsmall cell lung cancer. Eur Respir J 2013 Nov;42(5):1357-64 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23520312.

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Appendices


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