What are the optimal follow-up tests for people with lung cancer who have had curative intent treatment?

From Cancer Guidelines Wiki

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.[1][2][3] 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).[4] 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.[5][6][7] 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). [8]

PET CT, done at 3months, was shown to be more cost effective than CT, especially in asymptomatic patients.[9] 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).[10]

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.

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Evidence summary and recommendations

Evidence summary Level References
Low dose CT can be performed for follow up following curative treatment of lung cancer. III-2 [4]
Evidence-based recommendationQuestion mark transparent.png Grade
Low dose CT should be considered as part of the protocol for follow up of lung cancer patients.
Evidence summary Level References
PET-CT is an effective tool in detecting recurrence of lung cancer. IV [5], [6], [7]
Evidence-based recommendationQuestion mark transparent.png Grade
Consideration should be given to including PET-CT in the follow up for detection of recurrences after 6 months.

Practice pointQuestion mark transparent.png

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.

Practice pointQuestion mark transparent.png

PET-CT is not reimbursed for follow up of lung cancer patients.

Practice pointQuestion mark transparent.png

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

  1. Is PET-CT routinely required in the follow up of asymptomatic patients following curative treatment for lung cancer?
  2. What is the optimal timing and frequency for follow up surveillance with PET-CT?
  3. Is it cost-effective in an Australian setting for PET-CT to be included in the follow up investigations?
  4. Does PET-CT follow up improve survival compared to standard clinical follow up?

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  1. 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.
  2. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23649451.
  3. Vansteenkiste J, De Ruysscher D, Eberhardt WE, Lim E, Senan S, Felip E, et al. Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013 Oct;24 Suppl 6:vi89-98 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23860613.
  4. 4.0 4.1 Chiu CH, Chern MS, Wu MH, Hsu WH, Wu YC, Huang MH, et al. Usefulness of low-dose spiral CT of the chest in regular follow-up of postoperative non-small cell lung cancer patients: Preliminary report. J Thorac Cardiovasc Surg 2003 Jun;125(6):1300-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12830048.
  5. 5.0 5.1 Muzaffer Metin, Makbule Ergin, Okan Solak, Adnan Sayar, Murat Sezer, Atilla Pekcolaklar, Atilla Gürses. Effectiveness of PET Scan in Postoperative Long Term Follow up of Patients with Nonsmall Cell Lung Cancer. JCAM ;3(1):30-2 Available from: http://www.jcam.com.tr/files/KATD-489.pdf.
  6. 6.0 6.1 Hiroaki Toba, Shoji Sakiyama, Hideki Otsuka, Yukikiyo Kawakami, Hiromitsu Takizawa, Koichiro Kenzaki, Kazuya Kondo,vand Akira Tangokua. 18F-fluorodeoxyglucose positron emission tomography/computed tomography is useful in postoperative follow-up of asymptomatic non-small-cell lung cancer patients. Interact Cardiovasc Thorac Surg. ;15(5): 859–864. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480619/.
  7. 7.0 7.1 Dane B, Grechushkin V, Plank A, Moore W, Bilfinger T. PET/CT vs. non-contrast CT alone for surveillance 1-year post lobectomy for stage I non-small-cell lung cancer. Am J Nucl Med Mol Imaging 2013 Sep 19;3(5):408-16 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24116349.
  8. Antoniou AJ, Marcus C, Tahari AK, Wahl RL, Subramaniam RM. Follow-up or Surveillance (18)F-FDG PET/CT and Survival Outcome in Lung Cancer Patients. J Nucl Med 2014 Jul;55(7):1062-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24777290.
  9. van Loon J, Grutters JP, Wanders R, Boersma L, Dingemans AM, Bootsma G, et al. 18FDG-PET-CT in the follow-up of non-small cell lung cancer patients after radical radiotherapy with or without chemotherapy: an economic evaluation. Eur J Cancer 2010 Jan;46(1):110-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19944595.
  10. Pan Y, Brink C, Schytte T, Petersen H, Wu YL, Hansen O. Planned FDG PET-CT Scan in Follow-Up Detects Disease Progression in Patients With Locally Advanced NSCLC Receiving Curative Chemoradiotherapy Earlier Than Standard CT. Medicine (Baltimore) 2015 Oct;94(43):e1863 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26512597.

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