What are the optimal follow-up tests for people with lung cancer who have had curative intent treatment?
Systematic Review Evidence
There is little evidence to support the absolute benefit of follow up in patients following curative intent treatment for lung cancer. The appropriate follow up investigations are also not fully defined. The NCCN, ACCP and ESMO guidelines recommend 6 monthly CT scans for the first 2 years with subsequent annual low-dose CT scans. There is no recommendation on the role of PET-CT scans at present. The questions guiding the use of the investigations relate to the ability of the test to pick up progressive disease that would result in salvage/curative treatment and also cost-effectiveness.
History and clinical examination are recommended in all guidelines for follow up. There is limited evidence to support the role of chest radiography but it is still included in most guidelines.
Evaluating low-dose CT (LDCT), Chiu et al found that LDCT detected 85.7% of recurrences compared to standard dose scans. They suggest that they may be comparable to standard dose CT for follow up (p<0.001). In this study, there was correlation between SDCT and LDCT for detection of pulmonary, pleural and mediastinal recurrences. Low dose CT does have limitations in detecting distant and mediastinal metastases.
PET-CT has been demonstrated to have a high sensitivity and specificity with a low false positive rate. Antoniou evaluated the prognostic value of PET-CT when done after 6months following completion of treatment and found PET positivity to be associated with a lower survival in younger patients. The median survival with a positive PET was 32.9months compared to 81.6months with a negative scan (p = 0.0001). 
PET CT, done at 3months, was shown to be more cost effective than CT, especially in asymptomatic patients. The caveat to this was that the imaging depends on what society can afford.There is no evidence for cost-efficacy in the Australian setting and PET-CT is not reimbursed for follow up of lung cancer patients.
Pan et al found that the addition of PET-CT following curative chemoradiation allowed for higher probability of early detection of progression and these patients had a better performance status than those detected on CT (p=0.02).
There is no clear evidence demonstrating a survival benefit with the routine use of PET-CT for follow up after management of lung cancer. In consideration of the above, requests for PET-CT should be ideally discussed in the setting of a multi-disciplinary meeting.
Evidence summary and recommendations
|Low dose CT can be performed for follow up following curative treatment of lung cancer.||III-2|||
|Low dose CT should be considered as part of the protocol for follow up of lung cancer patients.||C|
|PET-CT is an effective tool in detecting recurrence of lung cancer.||IV||, , |
|Consideration should be given to including PET-CT in the follow up for detection of recurrences after 6 months.||D|
It is advisable to consider utilising PET-CT for follow up. There is no evidence to suggest a clear survival benefit even though the probability of detecting early recurrence is higher with PET-CT.
PET-CT is not reimbursed for follow up of lung cancer patients.
It is suggested that the use of PET-CT for follow up be initiated following discussion at a lung cancer multidisciplinary meeting (MDT).
Issues requiring further clinical research study
- Is PET-CT routinely required in the follow up of asymptomatic patients following curative treatment for lung cancer?
- What is the optimal timing and frequency for follow up surveillance with PET-CT?
- Is it cost-effective in an Australian setting for PET-CT to be included in the follow up investigations?
- Does PET-CT follow up improve survival compared to standard clinical follow up?
- National Comprehensive Cancer Network (NCCN). Non small cell lung cancer. Version 4.2016. Fort Washington (PA): National Comprehensive Cancer Network; 2016 Available from: https://www.nccn.org/store/login/login.aspx?ReturnURL=https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf.
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