The ability to develop evidence-based guidelines for surveillance and follow-up based on the literature suffers from the lack of randomised studies comparing empiric follow-up with specific follow-up strategies.

1 Follow-up of Patients Treated with Curative Intent

Guideline: For patients treated with curative intent, in the absence of symptoms, a history and physical examination should be performed every 3 months during the first 2 years; every 6 months thereafter through year 5; and yearly thereafter. Although it is reasonable to perform periodic chest radiographs as part of routine follow-up, there is no role for routine scanning (CT, MRI, radionuclide bone scan, PET) or bronchoscopy in asymptomatic patients. Smoking cessation and avoidance of occupational and environmental exposure to carcinogenic substances are recommended as effective interventions to reduce the risk of second primary NSCLC in curatively treated patients.

Level of Evidence: III

Grade of Recommendation: C

Patients in this category include those with resected Stage I, II and IIIA NSCLC (with or without post-operative adjuvant radiotherapy), stage III NSCLC patients treated with radical radiotherapy or combined modality therapy and limited stage SCLC patients treated with combined modality therapy. The responsible physician should be explicitly clarified by the doctor in charge at the BCCA. Patients on investigational trials should be monitored at intervals indicated by their respective studies.

The goal of monitoring patients after potentially curative therapy for lung cancer is to detect symptomatic progression of their disease which may benefit from therapeutic intervention or symptom management. Retrospective studies of lung cancer follow-up showed no evidence for an improved outcome from early detection of an asymptomatic recurrence and there was no evidence that more intense follow-up improved any outcome (Walsh 1995, Virgo 1995). Potentially, detection of a second primary could be of value but as with screening (section 3), such investigation has not been proven to reduce cancer mortality. Long-term survivors from lung cancer are potential candidates for early detection studies depending on the general condition of the patient and the likelihood that curative treatment could be undertaken in case of detection of a metachronous lung cancer. Other goals of follow-up include gathering outcome data (toxicity, survival) and provision of reassurance/psychological support.

Some asymptomatic patients or their physicians may seek further reassurance through performance of regular CT or MRI imaging procedures. The study of Walsh et al. showed that only 10% of asymptomatic recurrences and only 2.2% of all recurrences were detected by such tests. About 80% of relapses are detected by history/physical examination. Special investigations are recommended for symptomatic patients who are amenable to undergo therapeutic or symptomatic interventions.

2 Follow-up of Patients Treated With Palliative Intent

For patients treated with palliative intent, follow-up depends on symptomatology and treatment modality used. Efficacy and side effects of therapies deployed should be documented. Understandably, patients enjoying a palliative remission may develop unrealistic expectations for continued remission. A structured follow-up recommendation helps provide the reassurance and psychological support these patients need. The BCCA doctor in charge should explicitly clarify the physician in charge of palliative patient follow-up. For patients followed by their referring physicians, the BCCA physicians will act as consultants if requested.

Key References

1. Walsh GL, O'Connor M, Willis KM, et al: Is follow-up of lung cancer patients medically indicated and cost-effective. Ann Thorac Surg 60:1563-72, 1995.
2. Virgo KS, McKirgan LW, Caputo M, et al: Post treatment management options for patients with lung cancer. Ann Surg 222:700-710, 1995.
3. ASCO Special Article: Clinical practice guidelines for the treatment of unresectable non-small-cell lung cancer. J Clin Oncol 15:2996-3018, 1997

3 Follow-up of Patients Treated with Palliative Radiation Therapy

In general, after treatment, patients will be followed through their referring physician or family doctor unless the radiation oncologist involved states otherwise.

Key References:

1. Sullivan FJ. Palliative radiotherapy for lung cancer. Lung Cancer: Principles and Practice. Pass HI, Mitchell JB, Johnson DH, Turrisi AT. Lippincott-Raven, Philadelphia, 1996,pp775.
2. Bleehan N. Inoperable non-small cell lung cancer (NSCLC): a Medical Research Council randomized trial of palliative radiotherapy with two fractions or ten fractions. Br J Cancer 1991;63:265.
3. Medical research Council Lung Cancer Working Party. A Medical Research Council (MRC) randomised trial of palliative radiotherapy with two fractions or a single fraction in patients with inoperable non-small-cell lung cancer (NSCLC) and poor performance status. Br J Cancer 1992;65:934.