[IFCT-0302 trial: randomised study comparing two follow-up schedules in completely resected non-small cell lung cancer]

Follow-up strategies following completion of primary cancer treatment in adult cancer survivors

BACKGROUND

Most cancer survivors receive follow-up care after completion of treatment with the primary aim of detecting recurrence. Traditional follow-up consisting of fixed visits to a cancer specialist for examinations and tests are expensive and may be burdensome for the patient. Follow-up strategies involving non-specialist care providers, different intensity of procedures, or addition of survivorship care packages have been developed and tested, however their effectiveness remains unclear.

OBJECTIVES

The objective of this review is to compare the effect of different follow-up strategies in adult cancer survivors, following completion of primary cancer treatment, on the primary outcomes of overall survival and time to detection of recurrence. Secondary outcomes are health-related quality of life, anxiety (including fear of recurrence), depression and cost.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases and two trials registries on 11 December 2018 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised trials comparing different follow-up strategies for adult cancer survivors following completion of curatively-intended primary cancer treatment, which included at least one of the outcomes listed above. We compared the effectiveness of: 1) non-specialist-led follow-up (i.e. general practitioner (GP)-led, nurse-led, patient-initiated or shared care) versus specialist-led follow-up; 2) less intensive versus more intensive follow-up (based on clinical visits, examinations and diagnostic procedures) and 3) follow-up integrating additional care components relevant for detection of recurrence (e.g. patient symptom education or monitoring, or survivorship care plans) versus usual care.

DATA COLLECTION AND ANALYSIS

We used the standard methodological guidelines by Cochrane and Cochrane Effective Practice and Organisation of Care (EPOC). We assessed the certainty of the evidence using the GRADE approach. For each comparison, we present synthesised findings for overall survival and time to detection of recurrence as hazard ratios (HR) and for health-related quality of life, anxiety and depression as mean differences (MD), with 95% confidence intervals (CI). When meta-analysis was not possible, we reported the results from individual studies. For survival and recurrence, we used meta-regression analysis where possible to investigate whether the effects varied with regards to cancer site, publication year and study quality.

MAIN RESULTS

We included 53 trials involving 20,832 participants across 12 cancer sites and 15 countries, mainly in Europe, North America and Australia. All the studies were carried out in either a hospital or general practice setting. Seventeen studies compared non-specialist-led follow-up with specialist-led follow-up, 24 studies compared intensity of follow-up and 12 studies compared patient symptom education or monitoring, or survivorship care plans with usual care. Risk of bias was generally low or unclear in most of the studies, with a higher risk of bias in the smaller trials. Non-specialist-led follow-up compared with specialist-led follow-up It is uncertain how this strategy affects overall survival (HR 1.21, 95% CI 0.68 to 2.15; 2 studies; 603 participants), time to detection of recurrence (4 studies, 1691 participants) or cost (8 studies, 1756 participants) because the certainty of the evidence is very low. Non-specialist- versus specialist-led follow up may make little or no difference to health-related quality of life at 12 months (MD 1.06, 95% CI -1.83 to 3.95; 4 studies; 605 participants; low-certainty evidence); and probably makes little or no difference to anxiety at 12 months (MD -0.03, 95% CI -0.73 to 0.67; 5 studies; 1266 participants; moderate-certainty evidence). We are more certain that it has little or no effect on depression at 12 months (MD 0.03, 95% CI -0.35 to 0.42; 5 studies; 1266 participants; high-certainty evidence). Less intensive follow-up compared with more intensive follow-up Less intensive versus more intensive follow-up may make little or no difference to overall survival (HR 1.05, 95% CI 0.96 to 1.14; 13 studies; 10,726 participants; low-certainty evidence) and probably increases time to detection of recurrence (HR 0.85, 95% CI 0.79 to 0.92; 12 studies; 11,276 participants; moderate-certainty evidence). Meta-regression analysis showed little or no difference in the intervention effects by cancer site, publication year or study quality. It is uncertain whether this strategy has an effect on health-related quality of life (3 studies, 2742 participants), anxiety (1 study, 180 participants) or cost (6 studies, 1412 participants) because the certainty of evidence is very low. None of the studies reported on depression. Follow-up strategies integrating additional patient symptom education or monitoring, or survivorship care plans compared with usual care: None of the studies reported on overall survival or time to detection of recurrence. It is uncertain whether this strategy makes a difference to health-related quality of life (12 studies, 2846 participants), anxiety (1 study, 470 participants), depression (8 studies, 2351 participants) or cost (1 studies, 408 participants), as the certainty of evidence is very low.

AUTHORS' CONCLUSIONS

Evidence regarding the effectiveness of the different follow-up strategies varies substantially. Less intensive follow-up may make little or no difference to overall survival but probably delays detection of recurrence. However, as we did not analyse the two outcomes together, we cannot make direct conclusions about the effect of interventions on survival after detection of recurrence. The effects of non-specialist-led follow-up on survival and detection of recurrence, and how intensity of follow-up affects health-related quality of life, anxiety and depression, are uncertain. There was little evidence for the effects of follow-up integrating additional patient symptom education/monitoring and survivorship care plans.

A surveillance method-oriented detection of post-operative spatial-temporal recurrence for non-small cell lung cancer

Background

This study evaluated spatial-temporal recurrence patterns after curative resection for non-small cell lung cancer (NSCLC) to clarify and recommend appropriate post-operative surveillance.

Methods

A total of 2,486 consecutive patients between January 2005 and December 2012 with NSCLC (stage I-IIIA) who underwent definitive surgical resection were retrospectively analyzed. We used a hazard rate curve to evaluate event dynamics. Disease-free survival (DFS) was evaluated by the Kaplan-Meier method. Univariate and multivariate analyses with Cox proportional hazards regression identified risk factors that predicted DFS.

Results

The median follow-up was 50.1 months. Recurrences were diagnosed in 852 (34.3%) patients. Four hundred eighty-nine events first occurred in the chest, 177 in the brain, 117 in the bone, and 71 in the abdomen. Of all recurrences, 78.5% occurred in the first 3 years. Univariate and multivariate analyses identified the age at diagnosis (P<0.001), histology (P=0.023), tumor size (P<0.001), pathologic N stage (P<0.001), and grade (P=0.043) as independent risk factors for intra-thoracic recurrences. Histology (P<0.001), tumor size (P<0.001), surgical method (P=0.021), pathologic N stage (P<0.001), and grade (P=0.005) were independent to predict extra-thoracic recurrences. The hazard rate curve displayed an initial surge of time to any treatment failure during 12 months after surgery. Based on sub-group analysis, both intra- and extra-recurrences increased with stage and brain recurrences in stage IIIA occurred earlier than stage II. Hazard rate curve of brain recurrences in squamous cell carcinoma showed a moderate peak during 9-15 months. Hazard rate curves of brain and bone recurrences in adenocarcinoma displayed clear peaks at 9-27 and 15-30 months, respectively.

Conclusions

Intra- and extra-thoracic recurrences correlate with different clinicopathological factors. Brain MRI and bone ECT were recommended for selected patients in particular time to early detect extra-thoracic recurrences.

More Frequent Surveillance Following Lung Cancer Resection Is Not Associated With Improved Survival: A Nationally Representative Cohort Study

OBJECTIVE

To evaluate whether an association exists between the intensity of surveillance following surgical resection for non-small cell lung cancer (NSCLC) and survival.

BACKGROUND

Surveillance guidelines following surgical resection of NSCLC vary widely and are based on expert opinion and limited evidence.

METHODS

A Special Study of the National Cancer Database randomly selected stage I to III NSCLC patients for data reabstraction. For patients diagnosed between 2006 and 2007 and followed for 5 years through 2012, registrars documented all postsurgical imaging with indication (routine surveillance, new symptoms), recurrence, new primary cancers, and survival, with 5-year follow-up. Patients were placed into surveillance groups according to existing guidelines (3-month, 6-month, annual). Overall survival and survival after recurrence were analyzed using Cox Proportional Hazards Models.

RESULTS

A total of 4463 patients were surveilled with computed tomography scans; these patients were grouped based on time from surgery to first surveillance. Groups were similar with respect to age, sex, comorbidities, surgical procedure, and histology. Higher-stage patients received more surveillance. More frequent surveillance was not associated with longer risk-adjusted overall survival [hazard ratio for 6-month: 1.16 (0.99, 1.36) and annual: 1.06 (0.86-1.31) vs 3-month; P value 0.14]. More frequent imaging was also not associated with postrecurrence survival [hazard ratio: 1.02/month since imaging (0.99-1.04); P value 0.43].

CONCLUSIONS

These nationally representative data provide evidence that more frequent postsurgical surveillance is not associated with improved survival. As the number of lung cancer survivors increases over the next decade, surveillance is an increasingly important major health care concern and expenditure.

Predicting survival following surgical resection of lung cancer using clinical and pathological variables: The development and validation of the LNC-PATH score

INTRODUCTION

The aim of this study was to develop and validate a simple prognostic scoring system using readily available clinical and pathological variables that could stratify patients according to the risk of death following lung cancer resection. We hypothesized that by using additional pathological variables not accounted for by pathological stage alone coupled with markers of overall fitness a new prognostic tool could be developed.

METHODS

Multivariable logistic regression analysis of pathological and other clinical variables from patients undergoing surgical resection of non-small cell lung cancer (NSCLC) were used to determine factors independently associated with 2-year overall survival and so derive the scoring system. The model was then validated in an external multi-centre dataset.

RESULTS

Using multivariable logistic regression on a large dataset (n = 1,421) the 'LNC-PATH' (Lymphovascular invasion, N-stage, adjuvant Chemotherapy, Performance status, Age, T-stage, Histology) prognostic score was devised and then validated using an external dataset (n = 402). This can be used to risk stratify patients into low, moderate and high-risk groups with a statistically significant difference between the three groups in their survival distributions. 83.8% of patients in the low-risk group survived two years after surgery compared to 55.6% in the moderate-risk group and 26.2% in the high-risk group. The score was shown to perform moderately well with an Area Under the Receiver Operating Characteristic curve (AUROC) value of 0.76 (95% CI: 0.73-0.79) and 0.70 (95% CI: 0.64-0.76) in the derivation and validation cohorts respectively.

DISCUSSION

The LNC-PATH score predicts 2-year overall survival after surgery for NSCLC. This may allow the development of risk stratified follow-up protocols in survivorship clinics which could be the subject of future prospective studies.

Pattern of Imaging after Lung Cancer Resection. 1992-2005

RATIONALE

Imaging intensity after lung cancer resection performed with curative intent is unknown.

OBJECTIVES

To describe the pattern and trends in the use of computed tomography (CT) and positron emission tomography (PET) scans in patients after resection of early-stage lung cancer.

METHODS

Retrospective analysis of the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database. Subjects included 8,621 Medicare beneficiaries (age, ≥66 yr) who underwent lung cancer resection with curative intent between 1992 and 2005. A surveillance CT or PET examination was defined as CT or PET imaging performed in an outpatient setting on patients who did not undergo chest radiography in the preceding 30 days.

MEASUREMENTS AND MAIN RESULTS

Overall, imaging use was higher within the first 2 years versus Years 3-5 after surgical resection. Use of surveillance CT scans increased sharply from 13.7 to 57.3% of those diagnosed in 1996-1997 and 2004-2005, respectively. PET scan use increased threefold, from 6.2% in 2000-2001 to 19.6% in 2004-2005. In multivariable analyses, we observed a 32% increase in the odds of undergoing surveillance CT or PET imaging for every year of diagnosis between 1998 and 2005. There was no substantial decline in the odds of having a surveillance CT or PET scan during each successive follow-up period, suggesting no change in the intensity of surveillance over the first 5 years after surgical resection. The proportion of surveillance CT imaging performed at freestanding imaging centers increased from 18.0% in 1998-1999 to 30.6% in 2004-2005.

CONCLUSIONS

The use of CT and PET imaging for surveillance after curative-intent surgical resection of early-stage lung cancer increased sharply in the United States between 1997-1998 and 2005. In the absence of evidence demonstrating favorable outcomes, this practice was likely driven by prevailing expert opinion embedded in clinical practice guidelines made available during that time. Research is clearly needed to determine the role and optimal approach to surveillance thoracic imaging after surgical resection of lung cancer.

Adherence to surveillance guidelines in resected NSCLC: Physician compliance and impact on outcomes

BACKGROUND

Resected NSCLC guidelines have varying recommendations on appropriate post-operative surveillance. There is general consensus that patients require follow-up with clinic visits and/or CT scans every 6 months for the first 2 years. This study evaluated compliance with surveillance guidelines and the impact on outcomes.

METHODS

The BC Cancer Agency (BCCA) provides cancer control for 4.6 million individuals. Inclusion criteria included referred patients from 2005 to 2010, resected stage Ib/II NSCLC, minimum 2 years follow-up at the BCCA, no prior cancer within 5 years. Retrospective chart review collected baseline parameters, follow up visits, CT imaging, recurrence and death.

RESULTS

479 were referred and 263 were eligible. Baseline characteristics: median age 68, male 52%, current/former/never smoker 38/52/10%, stage Ib/II 51/49%, squamous/non 30%/70%. Adherence to visits and/or CT scans every 6 months in 2 years: clinic visits 77%, CT scans 35%, visit and/or CT 80%. Recurrence rate was 46% at 2 years. Surveillance below vs per/above guidelines; metastatic recurrence 57% vs 79% (p=0.28), curative intent treatment at recurrence 14% vs 9% (p=0.50), palliative systemic treatment given 14% vs 34% (p=0.42), DFS 66.6m vs 37.6m (p<0.001), OS 76.5m vs 37.7m (p<0.001).

CONCLUSIONS

Compliance with follow up recommendations for resected NSCLC was 80%. Guideline conformity did not increase the rate of curative treatment at recurrence nor did it increase the proportion of patients treated with palliative chemotherapy. Better adjuvant treatment and surveillance options are needed for resected NSCLC.

Lung cancer screening: Should we be excluding people with previous malignancy?

The National Lung Screening Trial (NLST) was a large, randomized, controlled study showing a 20% reduction of lung cancer mortality and 7% reduction of all cause mortality using annual low dose computed tomography (LDCT) in a high risk population. NLST excluded people with a previous history of cancer treatment within the past 5 years and all people with a history lung cancer. The aim of this work is to review how lung cancer screening trials addressed the confounding effect of previous malignancy. We also review the subsequent recommendations by the United States Preventative Task Force Services, multiple professional societies and the Center for Medicaid and Medicare Services which defer either to NLST criteria or, clinician judgment or refrain from asserting any recommendation on the topic, respectively. Implications of lung cancer screening in the setting of previous malignancies, specifically lung, head and neck, esophageal, gastric, breast, colorectal cancer and lymphoma are also discussed. With lung cancer screening, an antecedent malignancy introduces the possibility of discovering metastasis as well as lung cancer. In some circumstances diagnosis and treatment of oligometastatic disease may confer a survival benefit. The survival benefit of treating either lung cancer or oligometastatic disease as result of lung cancer screening has yet to be determined. Further studies are needed to determine the role of lung cancer screening in the setting of previous malignancy.

2nd ESMO Consensus Conference in Lung Cancer: locally advanced stage III non-small-cell lung cancer

To complement the existing treatment guidelines for all tumour types, ESMO organises consensus conferences to focus on specific issues in each type of tumour. The 2nd ESMO Consensus Conference on Lung Cancer was held on 11-12 May 2013 in Lugano. A total of 35 experts met to address several questions on non-small-cell lung cancer (NSCLC) in each of four areas: pathology and molecular biomarkers, first-line/second and further lines of treatment in advanced disease, early-stage disease and locally advanced disease. For each question, recommendations were made including reference to the grade of recommendation and level of evidence. This consensus paper focuses on locally advanced disease.

Does the method of radiologic surveillance affect survival after resection of stage I non-small cell lung cancer?

OBJECTIVES

Controversy persists regarding appropriate radiographic surveillance strategies after lung cancer resection. We compared the impact of surveillance computed tomography scan versus chest radiography in patients who underwent resection for stage I lung cancer.

METHODS

A retrospective analysis was performed of all patients undergoing resection for pathologic stage I lung cancer from January 2000 to April 2013. After resection, follow-up included routine history and physical examination in conjunction with chest radiography or computed tomography at the discretion of the treating physician. Identification of successive lung malignancy (ie, recurrence at any new site or new primary) and survival were recorded.

RESULTS

There were 554 evaluable patients, with 232 receiving routine postoperative computed tomography and 322 receiving routine chest radiography. Postoperative 5-year survival was 67.8% in the computed tomography group versus 74.8% in the chest radiography group (P = .603). Successive lung malignancy was found in 27% (63/232) of patients receiving computed tomography versus 22% (72/322) receiving chest radiography (P = .19). The mean time from surgery to diagnosis of successive malignancy was 1.93 years for computed tomography versus 2.56 years for chest radiography (P = .046). For the computed tomography group, 41% (26/63) of successive malignancies were treated with curative intent versus 40% (29/72) in the chest radiography group (P = .639). Cox proportional hazard analysis indicated imaging modality (computed tomography vs chest radiography) was not associated with survival (P = .958).

CONCLUSIONS

Surveillance computed tomography may result in earlier diagnosis of successive malignancy versus chest radiography in stage I lung cancer, although no difference in survival was demonstrated. A randomized trial would help determine the impact of postoperative surveillance strategies on survival.

Differences in patterns of recurrence in early-stage versus locally advanced non-small cell lung cancer

BACKGROUND

The benefits of screening for non-small cell lung cancer (NSCLC) have been established for high-risk individuals, and recent guidelines advocate continued surveillance after curative therapy. Yet the optimal posttreatment surveillance strategy remains to be determined. We compared patterns of recurrence and modes of detection in surgically treated patients with pathologic early-stage and locally advanced NSCLC.

METHODS

Consecutive patients who had undergone resection for stage I-IIIA NSCLC from 2004 to 2009 were identified from a prospectively maintained institutional database. All patients received interval chest computed tomography (CT) scans every 6 to 12 months after treatment.

RESULTS

In total, 1,640 patients were identified: 181 of 346 patients with stage IIIA NSCLC (52%) and 257 of 1,294 patients with stage I-II NSCLC (20%) experienced recurrences. Surveillance CT detected asymptomatic recurrences in 157 stage I-II patients (61%) and 89 stage IIIA patients (49%) (p=0.045). Symptoms led to detection of recurrences more often in stage IIIA patients (73, 40%) than in stage I-II patients (81, 32%). Distant recurrences were more common in stage IIIA patients than in stage I-II patients (153, 85%, vs 190, 74%; p=0.01). In stage IIIA patients, the risk of recurrence was highest during the first 2 years after operation, but it remained substantial into year 4.

CONCLUSIONS

Stage IIIA patients had fewer recurrences detected by surveillance CT, a higher rate of symptomatic presentation, a markedly higher risk of recurrence, and a higher propensity for distant recurrence. Surveillance strategies may need to account for stage-specific differences.

What is the most practical, optimal, and cost effective method for performing follow-up after lung cancer surgery, and by whom should it be done?

Surgery is the treatment of choice for early stage non-small cell lung cancer. In this context, postoperative follow-up is important to diagnose late postoperative complications, as well as to detect recurring cancer or new primaries as early as possible. There is, however, no high-quality evidence regarding the benefits of monitoring programs on survival and quality of life. Most studies recommend clinical and radiological follow-up (radiograph or chest computed tomography) performed more intensively during the first two years and annually thereafter. The physician doing the follow-up can be the thoracic surgeon, the diagnosing physician, or the family physician.

Surveillance of resected non-small cell lung cancer

Lung cancer is the most common cancer in the world. 15 % of all patients with lung cancer are diagnosed at an early stage, and surgery is the treatment of choice for them. 40 % of all patients survive more than 5 years after surgery, and most of them die as a result of systemic disease. Half of all recurrences are diagnosed within the first 24 months after curative treatment, and 90 % in the first 5 years. Despite this, it is not standardized who should do the monitoring, what additional tests are needed and how often should they be performed. We present here a review on the various recommendations in clinical guidelines.

Survival benefits from follow-up of patients with lung cancer: a systematic review and meta-analysis

INTRODUCTION

The burden of lung cancer is high for patients and carers. Care after treatment may have the potential to impact on this. We reviewed the published literature on follow-up strategies intended to improve survival and quality of life.

METHODS

We systematically reviewed studies comparing follow-up regimes in lung cancer. Primary outcomes were overall survival (comparing more intensive versus less intensive follow-up) and survival comparing symptomatic with asymptomatic recurrence. Quality of life was identified as a secondary outcome measure. Hazard ratios (HRs) and 95% confidence intervals from eligible studies were synthesized.

RESULTS

Nine studies that examined the role of more intensive follow-up for patients with lung cancer were included (eight observational studies and one randomized controlled trial). The studies of curative resection included patients with non-small cell lung cancer Stages I to III disease, and studies of palliative treatment follow-up included limited and extensive stage patients with small cell lung cancer. A total of 1669 patients were included in the studies. Follow-up programs were heterogeneous and multifaceted. A nonsignificant trend for intensive follow-up to improve survival was identified, for the curative intent treatment subgroup (HR: 0.83; 95% confidence interval: 0.66-1.05). Asymptomatic recurrence was associated with increased survival, which was statistically significant HR: 0.61 (0.50-0.74) (p < 0.01); quality of life was only assessed in one study.

CONCLUSIONS

This meta-analysis must be interpreted with caution due to the potential for bias in the included studies: observed benefit may be due to systematic differences in outcomes rather than intervention effects. Some benefit was noted from intensive follow-up strategies. More robust data, in the form of randomized controlled trials, are needed to confirm these findings as the review is based primarily on observational studies. Future research should also include patient-centered outcomes to investigate the impact of follow-up regimes on living with lung cancer and psychosocial well-being.

18FDG-PET-CT in the follow-up of non-small cell lung cancer patients after radical radiotherapy with or without chemotherapy: an economic evaluation

BACKGROUND

The optimal follow-up strategy of non-small cell lung cancer (NSCLC) patients after curative intent therapy is still not established. In a recent prospective study with 100 patients, we showed that a FDG-PET-CT 3 months after radiotherapy (RT) could identify progression amenable for curative treatment in 2% (95% confidence interval (CI): 1-7%) of patients, who were all asymptomatic. Here, we report on the economic evaluation of this study.

PATIENTS AND METHODS

A decision-analytic Markov model was developed in which the long-term cost-effectiveness of 3 follow-up strategies was modelled with different imaging methods 3 months after therapy: a PET-CT scan; a chest CT scan; and conventional follow-up with a chest X-ray. A probabilistic sensitivity analysis was performed to account for uncertainty. Because the results of the prospective study indicated that the advantage seems to be confined to asymptomatic patients, we additionally examined a strategy where a PET-CT was applied only in the subgroup of asymptomatic patients. Cost-effectiveness of the different follow-up strategies was expressed in incremental cost-effectiveness ratios (ICERs), calculating the incremental costs per quality adjusted life year (QALY) gained.

RESULTS

Both PET-CT- and CT-based follow-up were more costly but also more effective than conventional follow-up. CT-based follow-up was only slightly more effective than conventional follow-up, resulting in an incremental cost-effectiveness ratio (ICER) of euro 264.033 per QALY gained. For PET-CT-based follow-up, the ICER was euro 69.086 per QALY gained compared to conventional follow-up. The strategy in which a PET-CT was only performed in the asymptomatic subgroup resulted in an ICER of euro 42.265 per QALY gained as opposed to conventional follow-up. With this strategy, given a ceiling ratio of euro 80.000, PET-CT-based follow-up had the highest probability of being cost-effective (73%).

CONCLUSIONS

This economic evaluation shows that a PET-CT scan 3 months after (chemo)radiotherapy with curative intent is a potentially cost-effective follow-up method, and is more cost-effective than CT alone. Applying a PET-CT scan only in asymptomatic patients is probably as effective and more cost-effective. It is worthwhile to perform additional research to reduce uncertainty regarding the decision concerning imaging in the follow-up of NSCLC.