Follow Up for Stage IIIA Non-Small Cell Lung Cancer (NSCLC)
After therapy for stage IIIA NSCLC, my doctors said we would do follow up chest x-rays every 3 months for the next 2 years, and then twice a year for 3 years. I questioned why they would not do CT and or PET scans, and I was told that if metastasis is discovered, it would not change the result or the amount of time I would ultimately survive, regardless of how it is discovered. I was told waiting for symptoms will have the same net result and progression timeline as if it were discovered via CT or PET. I would think that the earlier metastasis is discovered and treatment begun, the more time I will have to slow or delay the progression.
For patients in remission from NSCLC staged IIIA or less, with no other symptoms, what follow-up tests do you normally order and with what frequency? Do you agree with the waiting for metastases approach?
Barbara Campling, MD, Medical Oncologist, responds:
Unfortunately, there is no straightforward answer for this. There are two places where oncologists look for guidelines. They are the National Guideline Clearinghouse and the National Comprehensive Cancer Network. Both groups have similar recommendations for lung cancer patients who have been treated with curative intent therapy (as in your case). In generally, patients should undergo surveillance with a medical history, physical examination, and imaging study (typically chest CT scan) every 3-12 months for 2 years, and then annually. Patients should be counseled on symptom recognition and should be advised to contact their physician if worrisome symptoms are recognized.
Both groups also "grade" the level of evidence, or proof, for their guidelines, and definitive evidence for a preferred surveillance timing and imaging strategy is lacking. The NCCN admits that although there is not evidence from clinical trials to support their surveillance recommendations, there is agreement amongst experts that this is the best monitoring plan.
The issue addressed by your physicians is that if metastases are detected in someone who has undergone treatment with curative intent, it is very unlikely that the patient will ever be cured with any subsequent therapy, except in the very rare situation where there is a single site of metastatic disease which can be treated aggressively with local therapy, typically surgery or radiation therapy. You are correct that a CT and/or a PET/CT scan are more sensitive than a plain chest X-ray in detecting recurrence or metastases, but they are also more expensive, a fact that must be considered when guidelines are developed. Neither guideline agency recommends following with PET scans. Emerging data has demonstrated that initiation of chemotherapy and other palliative therapies early after the detection of metastasis may improve survival time or quality of life compared to waiting until the patient becomes more symptomatic.
Another important reason for careful follow-up of lung cancer patients treated with curative intent is that they are always at risk for developing a second primary lung cancer. If a second primary is detected early, then the chance of cure is certainly increased.