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

1. Follow-up of stage I, II and IIIA NSCLC patients treated with curative intent

Follow-up recommendation

For patients with stage I, II and IIIA non-small cell lung cancer (NSCLC) who have had their cancer resected for curative intent with or without adjuvant chemotherapy:

• First follow up with surgeon: two to six weeks post-op assessment with a chest x-ray.
• Second follow up: three months post-op contrast enhanced chest computed tomography (CT) scan to establish a new baseline.
• Every six months for the first two years: chest imaging with low-dose, non-contrast chest CT scan in addition to medical history and physical examination, every six months for the first two years. Follow-up may be conducted by the surgeon/oncologist.
• After the first two years of follow up, patient has the option to continue follow-up with their surgeon, specialist or GP. Follow up includes chest imaging with a low-dose, non-contrast CT scan with a medical history and physical examination annually for 3 years to complete 5 years.
• In addition, smoking cessation and avoidance of occupational and environmental exposure to carcinogenic substances are recommended as effective intervention to reduce the risk of second primary NSCLC in curatively treated patients.

The goals of following patients with resected NSCLC are to:

1. Detect local or locoregional recurrences. Local recurrences happen in 10% of cases¹ and depending on staging can be treated with resection, salvage radiotherapy^2,3; or chemoradiotherapy.
2. Detect new primary lung cancers;
3. Provide reassurance/psychological support.

Evidence to support recommendation

There is little evidence from randomized trials for surveillance recommendations. The only prospective randomized study of follow up in resected NSCLC was the IFCT-0302 trial⁴ (NCT00198341) which was presented at ESMO 2017 in Madrid, Spain. This trial, which included 1775 patients with resected stage I-II-IIIA NSCLC, did not show a statistically significant difference in OS between patients who received CT scans as part of their follow-up and those who did not. Three-year disease-free survival rates and eight-year OS rates were similar between the two arms. Irregardless, clinical practice guidelines including the National Comprehensive Cancer Network⁵ and Up To Date⁶ recommend follow-up visits every six months for the first two years and annually for years 3-5 in order to detect recurrences that may be salvaged and detect new primaries.

Document last updated: August 6, 2019

Key references

1. Walsh, G.L., O'Connor. M., Willis, K.M., et al: Is follow-up of lung cancer patients after resection medically indicated and cost-effective? Ann. Thorac. Surg. 60:1563-70; discussion 1570-2, 1995
2. Hearn, J.W., Videtic, G.M., Djemil, T., et al: Salvage stereotactic body radiation therapy (SBRT) for local failure after primary lung SBRT. Int. J. Radiat. Oncol. Biol. Phys. 90:402-6, 2014
3. McAvoy, S., Ciura, K., Wei, C., et al: Definitive reirradiation for locoregionally recurrent non-small cell lung cancer with proton beam therapy or intensity modulated radiation therapy: predictors of high-grade toxicity and survival outcomes. Int. J. Radiat. Oncol. Biol. Phys. 90:819-27, 2014
4. Westeel, V., Barlesi, F., Foucher, P., et al: 1273O Results of the phase III IFCT-0302 trial assessing minimal versus CT-scan-based follow-up for completely resected non-small cell lung cancer (NSCLC). Annals of Oncology 28, 2017
5. NCCN Guidelines Version 4.2019; Non-Small Cell Lung Cancer, National Comprehensive Cancer Network, 2019
6. West, H.J., Vallieres, E., Schild, S.E.: Management of stage I and stage II non-small cell lung cancer: post therapy surveillance. https://www.uptodate.com (Accessed on August 6, 2019), Up To Date, 2019
   

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 BC Cancer doctor in charge should explicitly clarify the physician in charge of palliative patient follow-up. For patients followed by their referring physicians, the BC Cancer physicians will act as consultants if requested.

Key references

1. Walsh, G.L., O'Connor, M., Willis, K.M., et al: Is follow-up of lung cancer patients medically indicated and cost-effective. Ann. Thorac. Surg. 60:1563-72, 1995.
2. Virgo, K.S., McKirgan, L.W., 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, F.J. Palliative radiotherapy for lung cancer. Lung Cancer: Principles and practice. Pass, H.I., Mitchell, J.B., Johnson, D.H., Turrisi, A.T., 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.