Is follow-up of lung cancer patients after resection medically indicated and cost-effective?

The significance of regular chest computed tomography in postoperative surveillance for surgically resected non-small cell lung cancer based on TNM 8th staging system

OBJECTIVES

Although several societies recommend regular chest computed tomography (CT) scans for the surveillance of surgically resected non-small cell lung cancer (NSCLC), there is paucity of evidence to support these statements. This study aimed to clarify whether regular CT scans improved the prognosis of patients with surgically resected NSCLC based on TNM 8th classification.

METHODS

Patients with pathologic Stage 0-III NSCLC who underwent complete surgical resection other than sublobar resection procedures were enrolled in the study. For these patients, clinicopathological data and postoperative surveillance data were collected by the retrospective review of medical records. Patients were categorized into the chest X-ray (CXR) group or the CT group according to whether they were followed-up with basic examinations including CXR or basic examinations plus regular chest CT. Postoperative overall survival was compared between the two groups.

RESULTS

Six hundred sixty five patients were categorized into the CXR (n = 245) and CT (n = 420) groups. The clinicopathological backgrounds did not differ to a statistically significant extent. Recurrence was seen in 68 (27.3%) patients in the CXR group and 117 (27.8%) patients in the CT group. The 5-year overall survival rates of the two groups did not differ to a statistically significant extent (CXR, 76.5%; CT, 78.3%, P = 0.22).

CONCLUSION

Regular chest CT scans may not improve the prognosis of surgically resected NSCLC. Further study is warranted to precisely evaluate the benefit of CT-based postoperative surveillance of NSCLC.

Alectinib in Resected ALK-Positive Non-Small-Cell Lung Cancer

BACKGROUND

Platinum-based chemotherapy is the recommended adjuvant treatment for patients with resectable, ALK-positive non-small-cell lung cancer (NSCLC). Data on the efficacy and safety of adjuvant alectinib as compared with chemotherapy in patients with resected ALK-positive NSCLC are lacking.

METHODS

We conducted a global, phase 3, open-label, randomized trial in which patients with completely resected, ALK-positive NSCLC of stage IB (tumors ≥4 cm), II, or IIIA (as classified according to the seventh edition of the Cancer Staging Manual of the American Joint Committee on Cancer and Union for International Cancer Control) were randomly assigned in a 1:1 ratio to receive oral alectinib (600 mg twice daily) for 24 months or intravenous platinum-based chemotherapy in four 21-day cycles. The primary end point was disease-free survival, tested hierarchically among patients with stage II or IIIA disease and then in the intention-to-treat population. Other end points included central nervous system (CNS) disease-free survival, overall survival, and safety.

RESULTS

In total, 257 patients were randomly assigned to receive alectinib (130 patients) or chemotherapy (127 patients). The percentage of patients alive and disease-free at 2 years was 93.8% in the alectinib group and 63.0% in the chemotherapy group among patients with stage II or IIIA disease (hazard ratio for disease recurrence or death, 0.24; 95% confidence interval [CI], 0.13 to 0.45; P<0.001) and 93.6% and 63.7%, respectively, in the intention-to-treat population (hazard ratio, 0.24; 95% CI, 0.13 to 0.43; P<0.001). Alectinib was associated with a clinically meaningful benefit with respect to CNS disease-free survival as compared with chemotherapy (hazard ratio for CNS disease recurrence or death, 0.22; 95% CI, 0.08 to 0.58). Data for overall survival were immature. No unexpected safety findings were observed.

CONCLUSIONS

Among patients with resected ALK-positive NSCLC of stage IB, II, or IIIA, adjuvant alectinib significantly improved disease-free survival as compared with platinum-based chemotherapy. (Funded by F. Hoffmann-La Roche; ALINA ClinicalTrials.gov number, NCT03456076.).

Effect of initial recurrence site on the prognosis of different tissue types of non-small cell lung cancer: a retrospective cohort study

PURPOSE

To explore the correlation between the initial recurrence site and survival after recurrence (PRS) in non-small cell lung cancer (NSCLC).

METHODS

We collected 588 stages I-III NSCLC patients with recurrence after radical resection in Yunnan Cancer Hospital from January 2013 to December 2018. We used Kaplan-Meier survival curves to compare PRS in patients with different site recurrences. The univariate and multivariate Cox proportional hazard models were used to analyze the impact of the initial recurrence site on PRS.

RESULTS

The recurrence site included the lung (n = 109), brain (n = 113), bone (n = 79), abdomen (n = 28), pleura (n = 24), lymph node (n = 81), and multisite (n = 154). In the total population, patients with multisite recurrence had substantially worse PRS (24.8 months, 95% confidence interval [CI]: 17.46-32.20) than that of patients without multiple sites recurrence (42.2 months, 95% CI 32.24-52.10) (P = 0.026). However, patients with lung recurrence had better RFS (63.1 months, 95% CI 51.13-74.00) than those who did not (31.0 months, 95% CI 25.10-36.96) (P < 0.001). In adenocarcinoma, patients with pleural recurrence had substantially worse PRS (21.3 months, 95% CI 15.07-27.46) than that of patients without pleural recurrence (46.9 months, 95% CI 35.07-58.80) (P = 0.031). Multivariate Cox proportional hazards regression analysis revealed that lung recurrence (HR 0.58, 95% CI 0.40-0.82; P = 0.003) was independent protective prognostic factor for PRS in the total population, while pleural recurrence (HR 2.18, 95% CI 1.14-4.17; P = 0.018) was independent adverse prognostic factors for PRS in adenocarcinoma patients.

CONCLUSION

The initial recurrence site was associated with PRS in NSCLC patients. Identification of recurrence sites could guide the subsequent treatment.

A Graph-Based Approach to Identify Factors Contributing to Postoperative Lung Cancer Recurrence among Patients with Non-Small-Cell Lung Cancer

The accurate identification of the preoperative factors impacting postoperative cancer recurrence is crucial for optimizing neoadjuvant and adjuvant therapies and guiding follow-up treatment plans. We modeled the causal relationship between radiographical features derived from CT scans and the clinicopathologic factors associated with postoperative lung cancer recurrence and recurrence-free survival. A retrospective cohort of 363 non-small-cell lung cancer (NSCLC) patients who underwent lung resections with a minimum 5-year follow-up was analyzed. Body composition tissues and tumor features were quantified based on preoperative whole-body CT scans (acquired as a component of PET-CT scans) and chest CT scans, respectively. A novel causal graphical model was used to visualize the causal relationship between these factors. Variables were assessed using the intervention do-calculus adjustment (IDA) score. Direct predictors for recurrence-free survival included smoking history, T-stage, height, and intramuscular fat mass. Subcutaneous fat mass, visceral fat volume, and bone mass exerted the greatest influence on the model. For recurrence, the most significant variables were visceral fat volume, subcutaneous fat volume, and bone mass. Pathologic variables contributed to the recurrence model, with bone mass, TNM stage, and weight being the most important. Body composition, particularly adipose tissue distribution, significantly and causally impacted both recurrence and recurrence-free survival through interconnected relationships with other variables.

CT-derived body composition associated with lung cancer recurrence after surgery

OBJECTIVES

To evaluate the impact of body composition derived from computed tomography (CT) scans on postoperative lung cancer recurrence.

METHODS

We created a retrospective cohort of 363 lung cancer patients who underwent lung resections and had verified recurrence, death, or at least 5-year follow-up without either event. Five key body tissues and ten tumor features were automatically segmented and quantified based on preoperative whole-body CT scans (acquired as part of a PET-CT scan) and chest CT scans, respectively. Time-to-event analysis accounting for the competing event of death was performed to analyze the impact of body composition, tumor features, clinical information, and pathological features on lung cancer recurrence after surgery. The hazard ratio (HR) of normalized factors was used to assess individual significance univariately and in the combined models. The 5-fold cross-validated time-dependent receiver operating characteristics analysis, with an emphasis on the area under the 3-year ROC curve (AUC), was used to characterize the ability to predict lung cancer recurrence.

RESULTS

Body tissues that showed a standalone potential to predict lung cancer recurrence include visceral adipose tissue (VAT) volume (HR = 0.88, p = 0.047), subcutaneous adipose tissue (SAT) density (HR = 1.14, p = 0.034), inter-muscle adipose tissue (IMAT) volume (HR = 0.83, p = 0.002), muscle density (HR = 1.27, p < 0.001), and total fat volume (HR = 0.89, p = 0.050). The CT-derived muscular and tumor features significantly contributed to a model including clinicopathological factors, resulting in an AUC of 0.78 (95% CI: 0.75-0.83) to predict recurrence at 3 years.

CONCLUSIONS

Body composition features (e.g., muscle density, or muscle and inter-muscle adipose tissue volumes) can improve the prediction of recurrence when combined with clinicopathological factors.

Postoperative surveillance using low-dose computed tomography for non-small-cell lung cancer

OBJECTIVES

We retrospectively analysed the surgical prognosis of patients with pathological stage I non-small-cell lung cancer (NSCLC) who after complete resection underwent low-dose computed tomography (LDCT) or conventional CT as postoperative surveillance.

METHODS

We investigated 416 patients who underwent lobectomy or segmentectomy between January 2013 and December 2016. We compared the prognosis between the LDCT and conventional CT groups using the propensity score-matched analysis.

RESULTS

The median follow-up period was 57 months. Cancer recurrence occurred in 47 patients (11.3%). In the entire cohort (n = 416), recurrence-free survival (RFS) and overall survival (OS) were better in the LDCT group (P = 0.001 and 0.002, respectively). Both intrathoracic recurrence and distant metastasis were higher in the conventional group (P = 0.015 and 0.009, respectively). However, there was no statistical difference in the factors leading to recurrence detection (routine radiological examination, symptoms and elevated tumour markers: all P > 0.05). Both groups were matched using a ratio of 1:1. The area under the receiver operating characteristic curve was 0.788. A total of 226 patients were successfully matched. After matching, there was no statistical difference between the 2 groups for RFS and OS (P = 0.263 and 0.226). There were also no statistical differences in recurrence rate, the factors leading to recurrence detection or recurrence site (all P > 0.05).

CONCLUSIONS

After using propensity score matched, RFS and OS did not differ significantly between LDCT and conventional CT groups. Retrospective comparisons suggest no disadvantages of using LDCT for postoperative surveillance of pathological stage I NSCLC. Further validation will be needed in the future.

Monitoring of the presence of EGFR-mutated DNA during EGFR-targeted therapy may assist in the prediction of treatment outcome

The aim of our trial was to evaluate the prognostic significance of qualitative ctDNA analysis on different stages of EGFR mutated non-small cell lung cancer (NSCLC) treatment. We included 99 patients amendable for the first line treatment with either gefitinib/erlotinib (n = 87), afatinib (n = 10) or osimertinib (n = 2). Sequential qualitative analysis of ctDNA with cobas® EGFR Mutation Test v2 were performed before first dose, after 2 and 4 months of treatment, and on progression. Our analysis showed clinically significant heterogeneity of EGFR-mutated NSCLC treated with 1st line tyrosine kinase inhibitors (TKIs) in terms of progression-free and overall survival. When treated with conventional approach, i.e. monotherapy with TKIs, the patients falls into three subgroups based on ctDNA analysis before and after 2 months of treatment. Patients without detectable ctDNA at baseline (N = 32) possess the best prognosis on duration of treatment (PFS: 24.07 [16.8-31.3] and OS: 56.2 [21.8-90.7] months). Those who achieve clearance after two months of TKI (N = 42) have indistinguishably good PFS (19.0 [13.7 - 24.2]). Individuals who retain ctDNA after 2 months (N = 25) have the worst prognosis (PFS: 10.3 [7.0 - 13.5], p = 0.000). 9/25 patients did not develop ctDNA clearance at 4 months with no statistical difference in PFS from those without clearance at 2 months. Prognostic heterogeneity of EGFR-mutated NSCLC should be taken into consideration in planning further clinical trials and optimizing the outcome of patients.

Barriers to surveillance imaging adherence in early-staged lung cancer

Background

Frequency of post-treatment surveillance is highly variable following curative resection of non-small cell lung cancer (NSCLC). We sought to characterize surveillance practices after lobectomy for early-stage NSCLC and to identify the impact of various demographic factors on patterns of surveillance.

Methods

We included patients who underwent anatomic lobectomy for pathologic stage I NSCLC from 2007-2017. Demographic characteristics, post-operative imaging studies (internal and external), and travel distance were recorded. We defined the minimal standard of surveillance imaging studies (MSSIS) as ≥7 studies in the first 5 years (computed tomography/positron emission tomography). Patient sex, ethnicity, marital status, and distance traveled were evaluated as predictors of imaging receipt. Standard descriptive statistics, univariate, and multivariate analysis (MVR) were performed.

Results

A total of 1,288 patients were included. The mean age was 65.5±10.1 years, 589 (45.7%) were male, 1,081 (83.9%) were Caucasian, and 924 (71.7%) were married. Only 464 (36%) achieved MSSIS; being married [75.6% (351/464) vs. 68.8% (567/824), P=0.01] and having larger tumor size (2.63±0.04 vs. 2.49±0.05 cm, P=0.03) were both associated with MSSIS. Patients residing <100 miles from the hospital were more likely to have MSSIS, and more imaging at 24 months (4.1±2.2 vs. 3.7±2.0; P=0.006), 60 months (8.0±5.1 vs. 6.6±4.2, P=0.001) and overall (10±7.3 vs. 8.2±6.3; P=0.001). On MVR, tumor size and marital status were associated with MSSIS.

Conclusions

Two-thirds of patients at our institution did not undergo recommended surveillance imaging. Tumor size, being married, and living <100 miles from the medical center were associated with an increased number of imaging studies and greater adherence to guidelines.

Understanding the Attitudes and Beliefs of Oncologists Regarding the Transitioning and Sharing of Survivorship Care

Transitioning survivorship care from oncologists to primary care physicians (PCPs) is a reasonable alternative to oncologist-led care. This study assessed oncologists’ attitudes and beliefs regarding sharing/transitioning survivorship care. A prospective survey of oncologists within a regional cancer program assessing self-reported barriers and facilitators to sharing/transitioning survivorship care was disseminated. In total, 63% (n = 39) of surveyed oncologists responded. Patient preference (89%) and anxiety (84%) are key to transition of care decisions; reduced remuneration (95%) and fewer longitudinal relationships (63%) do not contribute. Oncologists agreed that more patients could be shared/transitioned. Barriers include treatment-related toxicities (82% agree), tumor-specific factors (60–90% agree) and perception of PCP willingness to participate in survivorship care (47% agree). Oncologists appear willing to share/transition more survivors to PCPs, though barriers exist that warrant further study. Understanding these issues is critical to developing policies supporting comprehensive survivorship care models that address both cancer and non-cancer health needs. The demonstrated feasibility of this project warrants a larger-scale survey of oncologists with respect to the transition of survivorship care to PCPs, to further inform effective interventions to support high-quality survivorship care.

[Implication of bronchopulmonary cancer patients in thoracic oncology]

Changed relationships between patient and health care provider have given patients a greater role in their care. Nowadays, they have the opportunity to be involved in decision-making regarding any diagnostic, therapeutic or monitoring intervention related to their disease. Access to international scientific data through the web, the activity of different patient associations, and the information given by their referring physician can enrich their knowledge about their disease and its possible treatments. In addition to the objective criteria usually assessed, the role currently assumed by patient associations in clinical research helps to identify their expectations. In addition, a number of new tools allow the thoracic oncologist to better understand patients' wishes. Health authorities' use of patient-reported outcomes and patients' use of digital applications contribute to improved survival without any deleterious impact on quality of life. Web applications designed to monitor a patient's toxicities during treatment are now commercially available. To meet our patients' expectations, we are called upon to incorporate these different digital tools into our daily practice.

Impact of the initial site of recurrence on prognosis after curative surgery for primary lung cancer

OBJECTIVES

This retrospective study aimed to elucidate the impact of the initial site of recurrence on relapse-free survival and post-recurrence survival (PRS) after the curative resection of primary lung cancer.

METHODS

We enrolled 325 patients who developed recurrence after curative resection of pathological stage I-IIIA primary lung cancer between January 2006 and December 2018 at the Kanagawa Cancer Center. Cases were classified as follows based on the initial site of recurrence: cervicothoracic lymph node (n = 144), lung (n = 121), pleural dissemination (n = 52), bone (n = 59), brain and meningeal dissemination (n = 50) and abdominal organ (n = 34) cases. The relapse-free survival and PRS of patients with and without recurrence at each site were compared using the log-rank test. The impact of the initial site of recurrence on PRS was analysed using the Cox proportional hazards model.

RESULTS

Relapse-free survival was significantly poorer in patients with abdominal organ recurrence than in patients without abdominal organ recurrence (11.5 vs 17.6 months, P = 0.024). The PRS of patients with bone and abdominal organ recurrences was worse than that of patients without bone (18.4 vs 31.1 months, P < 0.001) or abdominal organ (13.8 vs 30.6 months, P < 0.001) recurrence. Multiple recurrence sites were observed more frequently in patients with bone and abdominal organ recurrences. Bone [hazard ratio (HR) 2.13; P < 0.001] and abdominal organ metastasis (HR 1.71; P = 0.026) were independent poor prognostic factors for PRS.

CONCLUSIONS

This study suggests surveillance for abdominal organ recurrence in the early postoperative period. Patients with bone and abdominal organ recurrence should receive multimodality treatment to improve their prognosis.

Computed tomography follow-up identifies radically treatable new primaries after resection for lung cancer

OBJECTIVES

The optimal imaging programme for the follow-up of patients who have undergone resection of primary lung cancer is yet to be determined. We investigated the incidence and patterns of new and recurrent malignancy after resection for early-stage lung cancer in patients enrolled into a computed tomography (CT) follow-up programme.

METHODS

We reviewed the outcomes of consecutive patients who underwent CT follow-up after resection of early-stage primary lung cancer at the Oxford University Hospitals NHS Foundation Trust, between 2013 and 2017.

RESULTS

Four hundred and sixty-six consecutive patients underwent resection of primary lung cancer between 1 January 2013 and 31 March 2017. Three hundred and thirty-one patients (71.0%) were enrolled in CT follow-up. The median follow-up was 98 weeks (range 26-262). Sixty patients (18.2%) were diagnosed with programme-detected malignancy. Recurrence was diagnosed in 36 patients (10.9%), new primary lung cancer in 16 patients (4.8%) and non-lung primary tumours in 8 patients (2.4%). A routine CT scan identified the majority of new primary lung cancers (84.2%) and those with disease recurrence (85.7%). The majority of programme-detected malignancies were radically treatable (55%). The median survival of programme-detected cancers was 92.4 versus 23.0 weeks for patients with clinically detected tumours (P < 0.0001). Utilizing the CT scout image as a surrogate for chest X-ray, the sensitivity of this modality was 16.95% (8.44-28.97%) and specificity was 89.83% (79.17-96.18%). Negative likelihood ratio was 0.92 (0.8-1.07).

CONCLUSIONS

CT follow-up of surgically treated primary lung cancer patients identifies malignancy at a stage where radical treatment is possible in the majority of patients. Chest X-ray follow-up may not be of benefit following lung cancer resection.

Cost-Effectiveness of Surveillance Scanning Strategies after Curative Treatment of Non-Small-Cell Lung Cancer

BACKGROUND

After curative treatment of primary non-small-cell lung cancer (NSCLC), patients undergo intensive surveillance with the aim to detect recurrences from the primary tumor or metachronous second primary lung cancer as early as possible and improve overall survival. However, the benefit of surveillance is debated. Available evidence is of low quality and conflicting. Microsimulation modeling facilitates the exploration of the impact of different surveillance strategies and provides insight into the cost-effectiveness of surveillance.

METHODS

A microsimulation model was used to simulate a range of computed tomography (CT)-based surveillance schedules, differing in the frequency and duration of CT surveillance. The impact on survival, quality-adjusted life-years, costs, and cost-effectiveness of each schedule was assessed.

RESULTS

Ten of 108 strategies formed the cost-effectiveness frontier; that is, these were the strategies with the optimal cost-health benefit balance. Per person, the discounted QALYs of these strategies varied between 5.72 and 5.81 y, and discounted costs varied between €9892 and €19,259. Below a willingness-to-pay threshold of €50,000/QALY, no scanning is the preferred option. For a willingness-to-pay threshold of €80,000/QALY, surveillance scanning every 2 y starting 1 y after curative treatment becomes the best option, with €11,860 discounted costs and 5.76 discounted QALYs per person. The European Society for Medical Oncology guideline strategy was more expensive and less effective than several other strategies.

CONCLUSION

Model simulations suggest that limited CT surveillance scanning after the treatment of primary NSCLC is cost-effective, but the incremental health-benefit remains marginal. However, model simulations do suggest that the guideline strategy is not cost-effective.

Comparing the benefits of different radiological follow-up modalities in surgically resected non-small cell lung cancer (NSCLC). A single centre study, Leeds-UK

INTRODUCTION

Computerised Tomography (CT) scans have been proposed as a potentially superior modality compared with chest x-rays in the follow up of lung cancer patients. In 2014 our Trust introduced a survivorship programme that included routine CT scans. This study is designed to assess the impact of this programme on the rate of recurrence, the treatment intent of recurrence and overall survival.

MATERIALS AND METHODS

This was a retrospective review of 220 patients with surgically resected Stage I-III Non-Small Cell Lung Cancer (NSCLC). Data were collected for all patients treated in 2012 and 2013 that received chest x-ray follow up (Group A) and patients treated in 2015 that received CT scan based follow up (Group B).

RESULTS

The rate of recurrence was similar between the two groups (31% vs 29%). Group B had a trend towards increased radical treatment of recurrence but this was not statistically significant (33% vs 47%); χ² (1,N = 66)=1.24, P = 0.27. Group B also had an increased mean overall survival (30.8 months ±0.8 months (95% CI 29.2- 32.4 months) vs 34.1 months ±0.7 months (95% CI 32.8-35.5 months)); log Rank=6.3, P = 0.01.

CONCLUSIONS

This study showed a trend towards a higher rate of radical treatment for recurrence in the CT follow up group, which may suggest a possible advantage of CT scans over plain radiographs. However, the results should be interpreted with caution given potential confounders. Importantly, Group B had larger proportion of Stage I disease and nationwide there was an improvement in lung cancer outcomes. Overall this remains an interesting area of study.

Survival Outcomes of Salvage Therapy for Local and Regionally Recurrent NSCLC

Introduction

The treatment of locally recurrent NSCLC after initial curative therapy is variable. We sought to perform a real-world analysis of curative and palliative therapeutic strategies used in locally recurrent NSCLC and explore the impact of baseline factors and the previous and recurrent treatment on outcomes.

Methods

A retrospective cohort study was done including all patients with stage I to III NSCLC who were referred to BC Cancer and received curative-intent therapy between 2005 and 2012. Patients were followed up to determine whether they developed locoregional recurrence. Two cohorts were created: curative-intent treatment at recurrence (surgery, radiotherapy with ≥50Gy ± chemotherapy, stereotactic radiosurgery) and palliative treatment. The primary outcome was overall survival (OS).

Results

A total of 1571 patients received curative-intent therapy during the study period. Of these, 179 (11%) developed a local and regional recurrence. A total of 51 patients (28%) were treated with curative intent at recurrence (12 surgery, 39 radiotherapy ± chemotherapy), and 128 (72%) received palliative treatment only. Patients receiving curative-intent therapy were more likely to have an Eastern Cooperative Oncology Group performance status of 0 to 1 (90% versus 58%), earlier stage at diagnosis (51% stage I) and receive more aggressive staging investigations at recurrence, pathologic confirmation (75% versus 27%) and positron emission tomography (77% versus 27%). OS was longer in the cohort receiving curative-intent therapy, with an OS of 34.3 months versus 9.8 months (p < 0.001) in palliative treatment.

Conclusions

In this real-world population, isolated locoregional recurrences occurred in 11% of patients. Curative-intent treatment at recurrence is associated with a reasonable chance of long-term survival, making aggressive therapy of locoregional recurrences an important treatment consideration.

Impact of Surveillance After Lobectomy for Lung Cancer on Disease Detection and Survival

INTRODUCTION

Existing guidelines for surveillance after non-small-cell lung cancer (NSCLC) treatment are inconsistent and have relatively sparse supporting literature. This study characterizes detection rates of metachronous and recurrent disease during surveillance with computed tomography scans after definitive treatment of early stage NSCLC.

MATERIALS AND METHODS

The incidence of metachronous and recurrent disease in patients who previously underwent complete resection via lobectomy for stage IA NSCLC at a single center from 1996 to 2010 were evaluated. A subgroup analysis was used to compare survival of patients whose initial surveillance scan was 6 ± 3 months (early) versus 12 ± 3 months (late) after lobectomy.

RESULTS

Of 294 eligible patients, 49 (17%) developed recurrent disease (14 local only, 35 distant), and 45 (15%) developed new NSCLC. Recurrent disease was found at a mean of 22 ± 19 months, and new primaries were found at a mean of 52 ± 31 months after lobectomy (P < .01). Five-year survival after diagnosis of recurrent disease was significantly lower than after diagnosis of second primaries (2.3% vs. 57.5%; P < .001). In the subgroup analysis of 187 patients, both disease detection on the initial scan (2% [2/94] vs. 4% [4/93]; P = .44) and 5-year survival (early, 80.8% vs. late, 86.7%; P = .61) were not significantly different between the early (n = 94) and the late (n = 93) groups.

CONCLUSION

Surveillance after lobectomy for stage IA NSCLC is useful for identifying both new primary as well as recurrent disease, but waiting to start surveillance until 12 ± 3 months after surgery is unlikely to miss clinically important findings.

Salvage stereotactic body radiotherapy for post-operative oligo-recurrence of non-small cell lung cancer: A single-institution analysis of 59 patients

A standard treatment for patients with early-stage non-small cell lung cancer (NSCLC) who undergo surgery, and subsequently develop local failure or intrathoracic oligo-recurrence, has not yet been established. The present study aimed to assess the feasibility of stereotactic body radiotherapy (SBRT) for this subgroup of patients. Consequently, a retrospective analysis was conducted of patients with NSCLC recurrence who were treated with SBRT, and previously underwent curative surgical resection between October 2011 and October 2016. Post-SBRT survival [overall survival (OS); progression-free survival (PFS); and local control (LC)] and toxicity were analyzed. Prognostic factors for OS were identified using univariate and multivariate analysis. A total of 52 patients and 59 tumors were analyzed. The median follow-up time was 25 months (35 months for surviving patients), and median OS following salvage SBRT was 32 months. The 1- and 3-year OS rates were 84.4 and 67.8%, respectively. 1- and 3-year PFS rates were 80.8 and 58.7%, respectively. Only 4 patients (7.7%) developed local failure. Median LC was 71 months and 1- and 3-year LC rate were 97.9 and 94.9%, respectively. A total of 4 patients experienced grade 3 or higher adverse events (AEs) and two experienced grade 5 AEs (pneumonitis and hemoptysis). Central tumor location and the possibility of re-operation were independent prognostic factors for OS. The present study indicated that post-operative salvage SBRT is a promising therapeutic option for patients with NSCLC with locoregional or intrathoracic oligo-recurrence. We regard toxicity was also acceptable. However, further research is required on the appropriate selection of subjects, and stratification of the analysis by certain risk factors would increase the accuracy of the conclusions.

Evidence-based follow-up in lung cancer?

In 2012 approximately 410,000 patients were diagnosed with lung cancer and about 353,000 lung cancer deaths were registered in the European Union. Although lung cancer is still the leading cause of cancer-related death worldwide, advances in detection and treatment have increased the likelihood of long-term survival. In patients receiving definitive curative treatment for lung cancer guidelines suggest follow-up of patients using clinical and radiological examinations over a certain period of time. However, standards differ and there are no generally accepted follow-up recommendations. Aim of this short review is to summarize the currently available knowledge and guidelines regarding surveillance of patients receiving definitive lung cancer treatment.

Effectiveness of intensive clinical and radiological follow-up in patients with surgically resected NSCLC. Analysis of 2661 patients from the prospective MAGRIT trial

BACKGROUND

Limited evidence is available on effectiveness of clinicoradiological follow-up of early-stage NSCLC patients. MAGRIT was a phase III adjuvant RCT conducted in surgically resected stage IB-IIIA NSCLC patients, in which all participants had a prospectively defined intensive clinicoradiological follow-up.

METHODS

At patient-level data, we analyzed detection modality of disease recurrences and new primary lung cancer (i.e. detected by clinicoradiological scheduled exams versus by interim unscheduled exams), features associated with higher risk of locoregional and/or distant recurrence, and recurrence rates over time.

RESULTS

In the 2261 patients studied, there was a significant association between the type of recurrence and the modality of detection: 88.4% (95% CI, 84%-91%) of the locoregional recurrences and 93.2% (95% CI, 84%-99%) of the new primary lung cancers were detected by scheduled exams, whereas this was only 68.7% (95% CI, 65%-73%) for distant metastases (p < 0.001). Survival of patients with locoregional recurrence or new primary lung cancer detected by scheduled exams was significantly better as compared with those detected by unscheduled exams (HR 0.56, 95% CI 0.36-0.87; p = 0.01). Survival was similarly poor in patients with distant recurrences, both with scheduled and unscheduled detection (3-year survival after recurrence 22.0% and 21.8%, respectively). Recurrence rate was the highest in the first 18 months after surgery-with a peak between month 6 and 12-decreasing thereafter. The hazard of a second primary lung cancer was constant over time.

CONCLUSION

Intensive follow-up is effective in detecting locoregional recurrences and second primary lung cancers, with impact on patients' survival but did not influence the detection of distant recurrences.

Let us not underestimate the long-term risk of SPLC after surgical resection of NSCLC

OBJECTIVES

Several studies have reported that patients operated on for non-small cell lung cancer (NSCLC) are at high risk of second primary lung cancer (SPLC). However, widely varying estimates of this risk have been reported, with very few studies taking into account that these patients are at particularly high competing risk of death, due to recurrence of the initial disease and to comorbidities. Risk factor evaluation over time has significant repercussions on the post-surgery surveillance strategy offered for NSCLC. This study primarily sought to measure the risk of SPLC in a long-term follow-up series, using statistical methods considering competing risks of death.

MATERIALS AND METHODS

The cumulative SPLC risk was estimated using the cumulative incidence of patients with completely resected Stage I-III NSCLC diagnosed between 2002 and 2015 based on the Doubs and Belfort cancer registry (France). A proportional sub-distribution hazard model (_sdRH) was used to investigate factors associated with SPLC risk in the presence of competing risks.

RESULTS

Among the 522 patients, adenocarcinoma and Stage I or II disease accounted for 52.3% and 75.7% of patients, respectively. Overall, 84 patients developed SPLC (16.1%). The cumulative risk of SPLC was 20.2% at 10 years post-surgery (95% confidence interval [CI]: 15.3-23.2), and 25.2% (CI: 19.4-31.3) at 14 years post-surgery. On multivariate analysis, the SPLC risk was significantly higher in patients with postoperative thoracic radiotherapy (_sdRH 2.79; 95% CI: 1.41-5.52; p = 0.003).

CONCLUSION

This study using appropriate statistical methods to consider competing risks showed that after complete NSCLC resection, the cumulative incidence function of SPLC was high, with patients receiving postoperative thoracic radiotherapy at higher risk. These data support the need for life-long follow-up of patients who undergo NSCLC surgery, with the objective of screening for SPLC.

Outcomes of patients with disease recurrence after treatment for locally advanced non-small cell lung cancer detected by routine follow-up CT scans versus a symptom driven evaluation

OBJECTIVES

The majority of patients with locally advanced non-small cell lung cancer (LANSCLC) will recur after receiving multimodal treatment with curative intent. Current guidelines recommend routine follow-up with computerized tomography (CT) scans, though minimal data exist on the utility of this approach nor has an optimal follow-up strategy to detect recurrence been defined. This study examined whether survival varied if relapse was detected with scheduled follow-up CT versus symptoms, and whether the pattern of recurrence affected these outcomes.

MATERIALS AND METHODS

Single institution retrospective review of patients who had undergone definitive management of LANSCLC with chemoradiotherapy +/- surgical resection. Standard follow-up testing consisted of routine exam and chest CT beginning at every 3 months in the first year and decreasing to annually after the fifth year.

RESULTS

311 patients were assessed, of which 167 patients recurred and were evaluable. 104 progressions were detected by follow-up and 63 by symptoms. For the entire group, there was no difference in overall survival (OS) for those detected by scans vs. symptoms (7.6 vs. 6.1 months, p = 0.797). After excluding patients with oligometastatic (1-3) brain metastases (OBM), OS was superior in patients with scan detected relapse (7.5 vs. 3.4 months, p = 0.013).

CONCLUSIONS

Routine surveillance by CT chest detects more localized disease than symptom driven follow-up, though OS does not differ. This null result is largely driven by the favorable outcomes for patients with OBM who present symptomatically. A strategy of both chest and brain imaging could be considered and warrants further investigation.

Prognostic factors for post-recurrence survival in patients with completely resected Stage III (N2) non-small-cell lung cancer

OBJECTIVES

The aim of this study was to investigate the prognostic factors for post-recurrence survival (PRS) in patients with completely resected Stage III (N2) non-small-cell lung cancer.

METHODS

A number of clinicopathological factors were evaluated to identify the prognostic factors for recurrence-free survival using Cox proportional hazards models in 245 patients who underwent complete resection of pathological Stage III (N2) non-small-cell lung cancer. Additional post-recurrence data were evaluated, including the presence of symptoms of recurrence, the recurrence pattern, the treatment modality and the recurrence-free interval (RFI). The prognostic effects of clinicopathological factors before recurrence and the additional post-recurrence data on PRS were analysed.

RESULTS

A total of 124 patients experienced recurrence during a median follow-up period of 39.8 months. Twenty-one patients were symptomatic at the time of initial recurrence, and the mean RFI was 14.0 months. Loco-regional recurrence was observed in 38 (31%) patients, distant metastasis in 33 (27%) patients and both in 53 (42%) patients. The initial treatment modality was surgery in 17 (14%) patients, chemotherapy in 66 (53%) patients, radiotherapy in 17 (14%) patients and chemoradiotherapy in 18 (15%) patients. The median duration of PRS was 30.5 months (range 1-109 months), and the 1-, 3- and 5-year PRS rates were 72%, 43% and 23%, respectively. A shorter RFI and radiotherapy for the treatment of recurrence were found to be independent prognostic factors for PRS in the multivariable analysis.

CONCLUSIONS

The prognostic factors for recurrence-free survival were not associated with PRS, and a shorter RFI and radiotherapy for the treatment of recurrence were found to be negative prognostic factors for PRS.

Local ablative therapy with or without chemotherapy for non-small-cell lung cancer patients with postoperative oligometastases

Background

The optimal treatment strategy for patients with non-small-cell lung cancer (NSCLC) with postoperative oligometastases is poorly defined. This two-institution analysis sought to retrospectively compare the efficacy and toxicity of local ablative treatment plus chemotherapy vs local treatment alone in patients with NSCLC who developed oligometastases after surgery.

Patients and methods

Among patients who underwent surgery for stage I–III NSCLC, 163 patients with oligometastases were enrolled between 2005 and 2016 in this study. All patients had ≤5 metachronous metastases with a disease-free interval (DFI) of ≥6 months after surgery. Patients with a second primary cancer, local recurrence, or driver mutations were excluded. Overall survival (OS), progression-free survival (PFS), objective response rate (ORR), failure patterns, and treatment-related toxicities were compared between groups receiving local ablative treatment plus chemotherapy and local treatment alone.

Results

A total of 105 patients who underwent local ablative therapy combined with chemotherapy and 58 patients who received local ablative therapy alone were included in this study. The median follow-up was 19 (range, 1.5–107) months. The combination therapy group had a higher ORR than the local therapy alone group (66.7% vs 46.5%, P=0.012), while the median PFS was 10 vs 7 months (P=0.006) and the median OS was 19 vs 18.5 months (P=0.498), respectively. By multivariate analysis, combination therapy and DFI ≥24 months were associated with superior PFS. Age was the only independent prognostic factor for OS (P<0.001). The incidences of grade ≥3 adverse events were higher in the combination treatment group.

Conclusion

Local ablative therapy plus chemotherapy conferred higher ORR and prolonged PFS but did not improve OS in NSCLC patients with postoperative oligometastases. Further prospective and randomized trials are urgently needed to validate these findings.

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.

Analysis of Relapse Events After Definitive Chemoradiotherapy in Locally Advanced Non-Small-Cell Lung Cancer Patients

BACKGROUND

The appropriate follow-up frequency after definitive chemoradiotherapy (CRT) for locally advanced non-small-cell lung cancer patients is unknown. Although surveillance guidelines have been proposed, very few data support current recommendations. Here we analyze relapse events after CRT and investigate whether symptomatic relapses versus those detected by surveillance imaging influences outcomes.

PATIENTS AND METHODS

Stage III non-small-cell lung cancer patients treated with CRT at our institution between 2005 and 2014 were retrospectively analyzed. Relapse events were grouped into posttreatment intervals and analyzed with cumulative tables. Time to relapse and overall survival (OS) were compared between patients with relapse detection via symptomatic presentation versus surveillance imaging.

RESULTS

A total of 211 patients were identified for analysis. The median follow-up was 43 months for patients alive at the time of analysis. The median age was 63 years, and equal proportions had IIIA or IIIB disease. A total of 135 patients (64%) experienced disease relapse, and of these, 74% did so within 12 months. In those who did not experience relapse at ≤ 12 months, 16%, 6%, and < 5% experienced relapse during 12 to 24, 24 to 36, and > 36 months of follow-up, respectively. In patients with relapse, 56% presented symptomatically, which led to inferior median OS compared to those identified by surveillance imaging (23 vs. 36 months; P = .013).

CONCLUSION

This study identified that most relapses occur within 1 year of completing CRT, and approximately half of these occur within 6 months. A symptomatic relapse led to inferior OS. More aggressive surveillance imaging may therefore identify asymptomatic relapses that are amenable to earlier salvage therapy.

Development and Validation of Web-Based Nomograms to Precisely Predict Conditional Risk of Site-Specific Recurrence for Patients With Completely Resected Non-small Cell Lung Cancer: A Multiinstitutional Study

BACKGROUND

There is currently no consensus regarding the optimal postoperative follow-up strategy for patients with completely resected non-small cell lung cancer (NSCLC). We aimed to develop web-based nomograms to precisely predict site-specific postoperative recurrence in patients with NSCLC and to guide individual surveillance strategies including when to follow up and what diagnostic tests to perform.

METHODS

We investigated the pattern of recurrence in a series of 2,017 patients with NSCLC (squamous cell carcinoma and nonlepidic invasive adenocarcinoma) who underwent complete surgical resection at Fudan University Shanghai Cancer Center (development cohort), and developed web-based clinicopathologic prediction models for conditional risk of site-specific recurrence based on Cox regression. The variables used in the analysis included sex, age, smoking history, tumor size, tumor histology, lymphovascular invasion, visceral pleural invasion, and pathologic TNM stage. A separate cohort of 3,308 patients with NSCLC from Shanghai Chest Hospital was used for external validation.

RESULTS

In the development cohort and the external validation cohort for the established nomograms to predict overall recurrence, thorax recurrence, abdomen recurrence, neck recurrence, brain recurrence, and bone recurrence, the C-statistics of Harrell et al were 0.743 and 0.748, 0.728 and 0.703, 0.760 and 0.749, 0.779 and 0.757, 0.787 and 0.784, and 0.777 and 0.739, respectively. The calibration plots showed optimal agreement between nomogram-predicted 3-year recurrence-free survival and actual 3-year recurrence-free survival.

CONCLUSIONS

These user-friendly nomograms can precisely predict site-specific recurrence in patients with completely resected NSCLC, based on clinicopathologic features. They may help physicians to make individual postoperative follow-up plans.

Solid predominant histologic subtype and early recurrence predict poor postrecurrence survival in patients with stage I lung adenocarcinoma

Introduction

This study investigated the correlation between histologic predominant pattern and postrecurrence survival (PRS), and identified the clinicopathologic factors influencing PRS in patients with completely resected stage I lung adenocarcinoma.

Methods

A total of 136 stage I lung adenocarcinoma patients who experienced tumor recurrence after completely resection were included in this study. To analysis the association between histologic predominant pattern and PRS, invasive adenocarcinomas with mixed histologic components were divided into 2 groups: solid and nonsolid group (including lepidic, acinar, papillary, micropapillary) based on the histologic predominant pattern. PRS was analyzed to identify the prognostic predictors using the Kaplan-Meier approach and multivariable Cox models.

Results

For all stage I invasive adenocarcinoma patients, the majority of postsurgical recurrences occurred within 2 years. Patients with solid predominant histological pattern were associated with unfavorable PRS (HR, 2.40; 95%CI 1.13-5.08, p=.022). There was a significant difference for poor PRS for patients who diagnosed tumor recurrence shorter than 12 months after surgery (HR, 2.34; 95%CI 1.12-4.90, p=.024). Extrathoracic metastasis was associated with poor media PRS in univariable analysis (p =.011), however, there was no significant PRS difference in multivariable analysis (HR, 1.56; 95%CI 0.65-3.73, p=.322) compared with intrathoracic metastasis.

Conclusions

Solid predominant histologic subtype and recurrence free interval less than 12 months predict worse PRS in patients with stage I lung adenocarcinoma.

Playing the odds: lung cancer surveillance after curative surgery

PURPOSE OF REVIEW

After 'curative' resection, many patients are still at risk for further lung cancer, either as a recurrence or a new metachronous primary. In theory, close follow-up should improve survival by catching relapse early - but in reality, many experts feel that surveillance for recurrence is of uncertain value. In this article, we explore the reasons behind the controversy, what the current guidelines recommend, and what future solutions are in development that may ultimately resolve this debate.

RECENT FINDINGS

Although postoperative surveillance for a new lung cancer may impart a survival advantage, this benefit does not appear to extend to the phenomenon of recurrence. Nevertheless, close radiographic follow-up after curative resection is still recommended by most professional societies, with more frequent scanning in the first 2 years, and then annual screening thereafter. Given the radiation risk, however, low-dose and minimal-dose computed tomography options are under investigation, as well as timing scans around expected peaks of recurrence rather than a set schedule.

SUMMARY

Applying the same surveillance algorithm to all lung cancer patients after curative resection may not be cost-effective or reasonable, especially if there is no demonstrable mortality benefit. Therefore, future research should focus on finding safer nonradiographic screening options, such as blood or breath biomarkers, or developing nomograms for predicting which patients will relapse and require closer follow-up. Ultimately, however, better tools for surveillance may be moot until we develop better treatment options for lung cancer recurrence.

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.

Temporal and regional distribution of initial recurrence site in completely resected N1-stage II lung adenocarcinoma: The effect of postoperative adjuvant chemotherapy

OBJECTIVES

Understanding the timing and pattern of cancer recurrence is essential to explain the causes of treatment failure. We investigated the recurrence pattern and rate over time in patients with completely resected N1-stage II lung adenocarcinoma.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 333 patients who underwent complete surgical resection for N1-stage II lung adenocarcinoma.

RESULTS

The median recurrence-free survival (RFS) was 38.8 months and the 5-year RFS rate was 39.6%. Left-sided tumors, large tumor size, and lymph node (LN) ratio higher than 0.15 were significantly correlated with a worse RFS, whereas female sex, direct LN involvement, and adjuvant chemotherapy were significantly correlated with a better RFS. Among the 182 patients who experienced recurrences, 46 (25.3%) had only loco-regional recurrences and 136 (74.7%) had distant metastases. The organs most commonly involved in initial recurrence were the lungs (n = 89, 48.9%), followed by bone (n = 41, 22.5%) and the brain (n = 38, 20.9%). The recurrence hazard curve for the entire study population demonstrated a similarly shaped and sized initial and second peak at 15 and 23 months, and a third smaller peak during the fourth year. The recurrence hazard curve of patients who received adjuvant chemotherapy exhibited a more delayed and smaller first peak than those who did not receive adjuvant chemotherapy. The patients treated with adjuvant chemotherapy had a lower rate of distant metastasis (p = 0.037); adjuvant chemotherapy had no effect on brain metastasis (p = 0.640).

CONCLUSION

In the present cohort, the hazard curves suggested that bone and brain recurrences exhibited an earlier first peak, while lung recurrences presented later. Adjuvant chemotherapy not only reduced the recurrence hazard but also delayed the recurrence and altered the pattern of recurrence. However, these results need to be confirmed in a prospective study.

Surveillance imaging following definitive radiotherapy for non-small cell lung cancer: What is the clinical impact?

Lung cancer is the leading cause of cancer death worldwide. Recurrence rates at all stages are high, but evidence-based post-treatment surveillance imaging strategies to detect recurrence are poorly defined, and salvage options are frequently limited. A number of national and international oncology guidelines address post-treatment imaging, but are largely based on low-level, retrospective evidence because of a paucity of high-quality data, particularly in regard to cost-effectiveness and quality-of-life endpoints. Given the lack of randomized data addressing appropriate surveillance imaging modality and interval following definitive treatment of lung cancer, there remains an unmet clinical need. Meaningful surveillance endpoints should include the financial impact, patient quality-of-life outcomes, and access-to-care issues associated with intensive follow-up to ensure that guidelines reflect quality and sustainability. A need for prospective randomized data on the subject of imaging surveillance after definitive local therapy remains an unmet need, and an opportunity for collaboration and further research.

Randomized Trial Comparing a Web-Mediated Follow-up With Routine Surveillance in Lung Cancer Patients

Background

The use of web-based monitoring for lung cancer patients is growing in interest because of promising recent results suggesting improvement in cancer and resource utilization outcomes. It remains an open question whether the overall survival (OS) in these patients could be improved by using a web-mediated follow-up rather than classical scheduled follow-up and imaging.

Methods

Advanced-stage lung cancer patients without evidence of disease progression after or during initial treatment were randomly assigned in a multicenter phase III trial to compare a web-mediated follow-up algorithm (experimental arm), based on weekly self-scored patient symptoms, with routine follow-up with CT scans scheduled every three to six months according to the disease stage (control arm). In the experimental arm, an alert email was automatically sent to the oncologist when self-scored symptoms matched predefined criteria. The primary outcome was OS.

Results

From June 2014 to January 2016, 133 patients were enrolled and 121 were retained in the intent-to-treat analysis; 12 deemed ineligible after random assignment were not subsequently followed. Most of the patients (95.1%) had stage III or IV disease. The median follow-up was nine months. The median OS was 19.0 months (95% confidence interval [CI] = 12.5 to noncalculable) in the experimental and 12.0 months (95% CI = 8.6 to 16.4) in the control arm (one-sided P = .001) (hazard ratio = 0.32, 95% CI = 0.15 to 0.67, one-sided P = .002). The performance status at first detected relapse was 0 to 1 for 75.9% of the patients in the experimental arm and for 32.5% of those in the control arm (two-sided P < .001). Optimal treatment was initiated in 72.4% of the patients in the experimental arm and in 32.5% of those in the control arm (two-sided P < .001).

Conclusions

A web-mediated follow-up algorithm based on self-reported symptoms improved OS due to early relapse detection and better performance status at relapse.

Survival analyses in lung cancer

BACKGROUND

Although survival analyses represent one of the cornerstones in oncology in general, some aspects of the reported survival data in lung cancer patients are still not fully elucidated.

METHODS

After having defined several open questions, an evidence based approach was applied in order to answer these questions. Areas of interest were: (I) possible uncertainties in reported survival data; (II) survival surrogates; (III) recommended methods for evaluating progression free survival (PFS) as a surrogate endpoint in future datasets; (IV) postoperative lung cancer recurrence and survival.

RESULTS

In recent years, PFS has seen increasing use as a primary endpoint, particularly in phase II trials. This article focuses on the statistical aspects, and particularly on evaluating the ability of PFS to accurately predict the overall survival (OS) outcome. If the data are available from randomized trials, then the evaluation of trial level surrogacy should be carried out, in addition to the methods described in the paper. If it is not a case, the patient-level methods should be applied. Suggestions for "landmark analysis" are also given: (I) classify your cases according to progression status (progressed, progression-free, or unknown) at one or more time points of interest; (II) perform a separate Cox proportional hazards regression analysis for each time point; (III) determine and report the landmark time point where progression status best predicts survival according to the hazard ratios and P values; (IV) calculate the concordance index for each landmark analysis model. The concordance index (or "c-Index") is essentially the probability that for any two randomly selected cases, the case that is predicted to have the worst outcome, does in fact have the worst outcome.

CONCLUSIONS

the widening spectrum of diagnostic and treatment in pulmonary oncology imposes the need for an updated knowledge about statistical method that would fit best for the analysed problem.

Prognostic Factors of Survival after Recurrence in Patients with Resected Lung Adenocarcinoma

OBJECTIVE

Recurrence after surgical resection is the most common cause of treatment failure in patients with non-small-cell lung cancer. The aim of the study is to investigate the prognostic factors of postrecurrence survival (PRS) in patients of resected lung adenocarcinoma.

METHODS

The clinicopathological characteristics of 179 patients with recurrence after complete resection of lung adenocarcinoma at Taipei Veterans General Hospital between 2004 and 2010 were retrospectively reviewed. The prognostic and predictive effects of these clinicopathological variables in PRS were analyzed.

RESULTS

The pattern of recurrence included local only in 25 (15.4%), distant only in 56 (34.6%), and both local and distant in 81 (50.0%) of patients. The 2-year and 5-year PRS were 65.2% and 29.8%, respectively. The most common organ sites of metastasis were the contralateral lung (39.1%), followed by the brain (33.5%) and the bone (31.3%). Multivariate analysis revealed that micropapillary/solid predominant pattern group (versus acinar/papillary; hazard ratio = 2.615; 95% confidence interval: 1.395-4.901; p = 0.003) and no treatment for recurrence (p < 0.001) were significant prognostic factors of worse PRS. For patients receiving treatment for recurrence, micropapillary/solid predominant pattern group (versus acinar/papillary; hazard ratio = 2.570; 95% confidence interval: 1.357-4.865; p = 0.004) was a significant predictive factor of worse PRS. Treatment for recurrence with surgery (p = 0.067) tended to be a significant predictive factor of better PRS.

CONCLUSIONS

In lung adenocarcinoma, micropapillary/solid predominant pattern group (versus acinar/papillary) was a significant poor prognostic factor for PRS.

Normalization of Exhaled Carbonyl Compounds After Lung Cancer Resection

Background

Quantitative analysis of specific exhaled carbonyl compounds (ECCs) has shown promise for the detection of lung cancer. The purpose of this study is to demonstrate the normalization of ECCs in patients after lung cancer resection.

Methods

Patients from a single center gave consent and were enrolled in the study from 2011 onward. Breath analysis was performed on lung cancer patients before and after surgical resection of their tumors. One liter of breath from a single exhalation was collected and evacuated over a silicon microchip. Carbonyls were captured by oximation reaction and analyzed by mass spectrometry. Concentrations of four cancer-specific ECCs were measured and compared by using the Wilcoxon test. A given cancer marker was considered elevated at 1.5 or more standard deviations greater than the mean of the control population.

Results

There were 34 cancer patients with paired samples and 187 control subjects. The median values after resection were significantly lower for all four ECCs and were equivalent to the control patient values for three of the four ECCs.

Conclusions

The analysis of ECCs demonstrates reduction to the level of control patients after surgical resection for lung cancer. This technology has the potential to be a useful tool to detect disease after lung cancer resection. Continued follow-up will determine whether subsequent elevation of ECCs is indicative of recurrent disease.

Monitoring and management of lung cancer patients following curative-intent treatment: clinical utility of 2-deoxy-2-[fluorine-18]fluoro-d-glucose positron emission tomography/computed tomography

A large number of studies have demonstrated that 2-deoxy-2-[fluorine-18]fluoro-d-glucose positron emission tomography/computed tomography (FDG-PET/CT) is superior to conventional modalities for the diagnosis of lung cancer and the evaluation of the extent of the disease. However, the efficacy of PET/CT in a follow-up surveillance setting following curative-intent treatments for lung cancer has not yet been established. We reviewed previous papers and evaluated the potential efficacy of PET-CT in the setting of follow-up surveillance. The following are our findings: 1) PET/CT is considered to be superior or equivalent to conventional modalities for the detection of local recurrence. However, inflammatory changes and fibrosis after treatments in local areas often result in false-positive findings; 2) the detection of asymptomatic distant metastasis is considered to be an advantage of PET/CT in a follow-up setting. However, it should be noted that detection of brain metastasis with PET/CT has some limitation, similar to its use in pretreatment staging; 3) additional radiation exposure and higher medical cost arising from the use of PET/CT should be taken into consideration, particularly in patients who might not have cancer after curative-intent treatment and are expected to have a long lifespan. The absence of any data regarding survival benefits and/or improvements in quality of life is another critical issue. In summary, PET/CT is considered to be more accurate and sensitive than conventional modalities for the detection of asymptomatic recurrence after curative-intent treatments. These advantages could modify subsequent management in patients with suspected recurrence and might contribute to the selection of appropriate treatments for recurrence. Therefore, PET/CT may be an alternative to conventional follow-up modalities. However, several important issues remain to be solved. PET/CT in a follow-up surveillance setting is generally not recommended in clinical practice at the moment.

Prediction and prognostic factors of post-recurrence survival in recurred patients with early-stage NSCLC who underwent complete resection

BACKGROUND

This study aimed to evaluate prognostic factors of post-recurrence survival (PRS) and to improve survival in recurred patients with early-stage non-small cell lung cancer (NSCLC).

METHODS

The 141 patients with recurrence after complete resection of stage I and II NSCLC between 1995 and 2012 was retrospectively reviewed. Overall PRS and PRS of the patient groups stratified according to the sum of their own risk scores were analyzed.

RESULTS

The patterns of recurrence of 141 patients included local only in 40(28.4%), distant only in 86 (61%) and both in 15 (10.6%) patients. Of 141 patients, 110 patients received post-recurrence therapy. The overall 1- and 3-year PRS rates were 50.7% and 28.4%, respectively. Extensive pulmonary resection (P=0.001), poor histologic differentiation (P=0.009), symptom at initial recurrence (P=0.000), no pulmonary metastasis (P=0.006), no post-recurrence therapy (P=0.001) were significant risk factors in univariate analysis. Multivariate analysis revealed that extent of pulmonary resection [hazard ratio (HR), 2.039; 95% confidence interval (CI), 1.281 to 3.244; P=0.003; risk score 1.0], histologic differentiation HR, 3.125; 95% CI, 1.976 to 4.941; P=0.000; risk score 1.5), symptom (HR, 3.154; 95% CI, 2.000 to 4.972; P=0.000; risk score 1.5) and post-recurrence therapy (HR, 2.330; 95% CI, 1.393 to 3.899; P=0.001; risk score 1.1) were significant prognostic factors. The recurred patients whose risk score sums were 1.1 or less were assigned to Group I; between 1.5 and 2.1, to Group II; and more than 2.5, to Group III. Significant differences in their PRS rates were confirmed (P=0.000).

CONCLUSIONS

Extent of pulmonary resection, histologic differentiation, symptom and post-recurrence therapy are a prognostic factor for PRS. Based on the hazard ratios of each factors, the risk scores were yielded. And the recurred patients were stratified according to the sum of their risk scores based on their PRS rates. Therefore, these results may help advancements in making predictions for their prognosis and the improvement of PRS.

Differences in the prognostic significance of the SUVmax between patients with resected pulmonary Adenocarcinoma and squamous cell carcinoma

BACKGROUND

The purpose of this study was to determine the prognostic significance of the maximum standardized uptake value (SUVmax) on F-18-fluorodeoxyglucose (FDG)-positron emission tomography (PET) in patients undergoing surgical treatment for non-small cell lung cancer.

MATERIALS AND METHODS

Seventy-eight consecutive patients (58 with adenocarcinomas, 20 with squamous cell carcinomas) treated with potentially curative surgery were retrospectively reviewed.

RESULTS

The SUVmax was significantly higher in the patients with recurrent than with non-recurrent adenocarcinoma (p<0.01). However, among the patients with squamous cell carcinoma, there were no differences with or without recurrence (p=0.69). Multivariate analysis indicated that the SUVmax of adenocarcinoma lesions was a significant predictor of disease-free survival (p=0.04). In addition, an SUVmax of 6.19, the cut-off point based on ROC curve analysis of the patients with pathological IB or more advanced stage adenocarcinomas, was found to be a significant predictor of disease-free survival (p<0.01).

CONCLUSIONS

SUVmax is a useful predictor of disease-free survival in patients with resected adenocarcinoma, but not squamous cell carcinoma. Patients with adenocarcinoma exhibiting an SUVmax above 6.19 are candidates for more intensive adjuvant therapy.

Stereotactic body radiation therapy for a new lung cancer arising after pneumonectomy: dosimetric evaluation and pulmonary toxicity

OBJECTIVE

To evaluate the tolerance of stereotactic body radiation therapy (SBRT) for the treatment of secondary lung tumours in patients who underwent previous pneumonectomy.

METHODS

12 patients were retrospectively analysed. The median maximum tumour diameter was 2.1 cm (1-4.5 cm). The median planning target volume was 20.7 cm(3) (2.4-101.2 cm(3)). Five patients were treated with a single fraction of 26 Gy and seven patients with fractionated schemes (3 × 10 Gy, 4 × 10 Gy, 4 × 12 Gy). Lung toxicity, correlated with volume (V) of lung receiving >5, >10 and >20 Gy, local control and survival rate were assessed. Median follow-up was 28 months.

RESULTS

None of the patients experienced pulmonary toxicity > grade 2 at the median dosimetric lung parameters of V5, V10 and V20 of 23.1% (range 10.7-56.7%), 7.3% (2.2-27.2%) and 2.7% (0.7-10.9%), respectively. No patients required oxygen or had deterioration of the performance status during follow-up if not as a result of clinical progression of disease. The local control probability at 2 years was 64.5%, and the overall survival at 2 years was 80%.

CONCLUSION

SBRT appears to be a safe and effective modality for treating patients with a second lung tumour after pneumonectomy.

ADVANCES IN KNOWLEDGE

Our results and similar literature results show that when keeping V5, V10 V20 <50%, <20% and <7%, respectively, the risk of significant lung toxicity is acceptable. Our experience also shows that biologically effective dose 10 >100 Gy, necessary for high local control rate, can be reached while complying with the dose constraints for most patients.

Predictors of imaging surveillance for surgically treated early-stage lung cancer

BACKGROUND

Current guidelines recommend routine imaging surveillance for patients with non-small cell lung cancer (NSCLC) after treatment. Little is known about surveillance patterns for patients with surgically resected early-stage lung cancer in the community at large. We sought to characterize surveillance patterns in a national cohort.

METHODS

We conducted a retrospective study using the Surveillance, Epidemiology, and End-Results (SEER)-Medicare database (1995-2010). Patients with stage I/II NSCLC treated with surgical resection were included. Our primary outcome was receipt of imaging between 4 and 8 months after the surgical procedure. Covariates included demographics and comorbidities.

RESULTS

Chest radiography (CXR) was the most frequent initial modality (60%), followed by chest computed tomography (CT) (25%). Positron emission tomography (PET) was least frequent as an initial imaging modality (3%). A total of 13% of patients received no imaging within the initial surveillance period. Adherence to National Comprehensive Cancer Network (NCCN) guidelines for imaging by overall prevalence was 47% for receipt of CT; however, rates of CT increased over time from 28% to 61% (p < 0.01). Reduced rates of CT were associated with stage I disease and surgical resection as the sole treatment modality.

CONCLUSIONS

Imaging after definitive surgical treatment for NSCLC predominantly used CXR rather than CT. Most of this imaging is likely for surveillance, and in that context CXR has inferior detection rates for recurrence and new cancers. Adherence to guideline-recommended CT surveillance after surgical treatment is poor, but the reasons are multifactorial. Efforts to improve adherence to imaging surveillance must be coupled with greater evidence demonstrating improved long-term outcomes.