What is the optimal model (provider) of care for the follow up of people with lung cancer who have had curative intent treatment?

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There is limited evidence on the optimal follow up model, either specialist (surgeon or physician), clinical nurse specialist or family physician driven.

In a randomised controlled trial, Moore et al, evaluated nurse led follow up looking at patient quality of life (QOL) and patient satisfaction.They found that patients had more satisfaction at 3 months with nurse led follow up, fewer medical consultations and a shorter time to symptomatic progression possibly related to the education they received regarding the symptoms - 6 vs 10.2 months (p = 0.004). There was no survival difference with nurse led follow up (p = 0.99). [1] This led to the NICE and Scottish guidelines being amended to include the role of the clinical nurse specialist in the follow up of lung cancer patients in a complementary fashion.[2][3]

Gilbert 2000 found no survival differences between surgeon and general practitioner follow up although the costs were higher with surgical follow up. In addition, more recurrences were found by the GP, mainly with history and clinical examination. [4]

Evaluating the role of telephonic nurse led follow up on symptoms and QOL in a quasi-experimental study of non-surgical patients, it was found that patients in this group had better social functioning and QOL and less side-effects with chemotherapy - believed to be related to the education regarding symptoms and more support. [5]

Comparing specialist with nurse and GP follow up, Cox 2006 found patients were happier with specialist follow up over nursing (p = 0.018) but favoured nurses over GP (p = 0.012). In an outpatient setting, 20% of patients were suitable for nurse led follow up.[6]

The American College of Chest Physicians (ACCP) have a level 1C recommendation for follow up with the original physician.[7] In a systematic review, Schmidt-Hansen 2012 suggested that all patients be offered an initial 6 week review with a specialist to discuss the ongoing review and follow up plan with early involvement of a clinical nurse specialist.[8] Nakamura 2010 found that physician led follow up was associated with a better survival over surgical follow up (p = 0.0009). This was confounded by the fact that the methods of follow up were different in the 2 groups with surgeons not using CT scans. In addition, looking at the more recent cases (post 1994), there was no survival difference.[9]

There is insufficient evidence to support a specific follow up model. Current follow up with a multidisciplinary approach is advocated with specialist (either surgeon or physician) follow up, complemented by clinical nurse specialists and involvement of the GP.[3]

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Evidence summary and recommendations

Evidence summary Level References
Specialist follow up should be offered to all patients following curative intent treatment for lung cancer. III-2 [8]
Evidence-based recommendationQuestion mark transparent.png Grade
A multidisciplinary approach to follow up is ideal, involving the treating specialists, family physician and clinical nurse specialists.
Evidence summary Level References
The evidence suggests that patient satisfaction is improved with nurse involvement in the follow up team. II [1]
Evidence-based recommendationQuestion mark transparent.png Grade
It is recommended that a nurse specialist ideally be involved, as an member of the team, in the follow up team for patients receiving curative intent treatment for lung cancer.

Issues requiring more clinical research study

  1. How do we streamline the follow up to reduce duplication of tests and follow up appointments?
  2. How do we incorporate modern technology and social media in the follow up of patients following curative treatment for NSCLC?
  3. Can we incorporate apps to facilitate follow up for lung cancer?

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  1. 1.0 1.1 Moore S, Corner J, Haviland J, Wells M, Salmon E, Normand C, et al. Nurse led follow up and conventional medical follow up in management of patients with lung cancer: randomised trial. BMJ 2002 Nov 16;325(7373):1145 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12433764.
  2. National Institute for Health and Care Excellence (NICE). Lung cancer:diagnosis and management (update). Manchester, UK; 2011 Available from: https://www.nice.org.uk/guidance/cg121/resources/lung-cancer-diagnosis-and-management-35109444863941.
  3. 3.0 3.1 Scottish Intercollegiate Guidelines Network (SIGN). Sign 137: Management of lung cancer. A national clinical guideline. Edinburgh: Scottish Intercollegiate Guidelines Network; 2014 Available from: http://www.sign.ac.uk/guidelines/fulltext/137/index.html.
  4. Gilbert S, Reid KR, Lam MY, Petsikas D. Who should follow up lung cancer patients after operation? Ann Thorac Surg 2000 Jun;69(6):1696-700 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10892909.
  5. Hintistan S, Nural N, Cilingir D, Gursoy A. Therapeutic Effects of Nurse Telephone Follow-up for Lung Cancer Patients in Turkey. Cancer Nurs 2016 Dec 12 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27977427.
  6. Cox K, Wilson E, Heath L, Collier J, Jones L, Johnston I. Preferences for follow-up after treatment for lung cancer: assessing the nurse-led option. Cancer Nurs 2006 May;29(3):176-87 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16783116.
  7. Colt HG, Murgu SD, Korst RJ, Slatore CG, Unger M, Quadrelli S. Follow-up and surveillance of the patient with lung cancer after curative-intent therapy: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013 May;143(5 Suppl):e437S-54S Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23649451.
  8. 8.0 8.1 Schmidt-Hansen M, Baldwin DR, Hasler E. What is the most effective follow-up model for lung cancer patients? A systematic review. J Thorac Oncol 2012 May;7(5):821-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22481234.
  9. Nakamura R, Kurishima K, Kobayashi N, Ishikawa S, Goto Y, Sakai M, et al. Postoperative follow-up for patients with non-small cell lung cancer. Onkologie 2010;33(1-2):14-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20164657.

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