The American Society of Clinical Oncology (ASCO) issued a clinical guideline recommending that patients with lung cancer should undergo surveillance imaging for recurrence every 6 months for 2 years after receiving curative-intent therapy.
The guideline — which was published in Journal of Clinical Oncology — also endorsed annual surveillance after 2 years for the detection of new primary lung cancers, and identified chest computed tomography (CT) as the most effective form of surveillance imaging.
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ASCO convened an expert panel to determine optimal surveillance practices for patients with localized non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC), who are often treated with curative intent. Surveillance is routinely used to detect and treat recurrences, but the practices governing surveillance are not always evidence based.
“Unfortunately, two-thirds of patients with lung cancer who relapse present with metastatic incurable disease, and, as yet, there is limited evidence to support the concept that detection and treatment of asymptomatic metastatic recurrences improves outcome due to the concern of lead-time bias,” the panel wrote. “However, patients may present with a potentially curable lung cancer recurrence or a new primary lung cancer, and prompt identification of these patients may improve outcomes.”
The panel performed a literature review and identified 14 relevant studies to form their knowledge base. The majority of studies (n = 7) were retrospectives; others included prospective cohort trials (n = 3), randomized controlled trials (n = 2), case-control studies (n = 1), systematic review and meta-analysis (n = 1).
The guideline aimed to answer five clinical questions:
What should be the frequency of surveillance imaging?
What is the optimal imaging modality?
Are there any patient factors such as performance status or age limits that would preclude surveillance?
Is there a role for circulating biomarkers in surveillance?
What is the role of brain magnetic resonance imaging (MRI) for surveillance in curatively treated lung cancer?
The panel recommended, by informal consensus, that patients treated with curative-therapy should undergo surveillance imaging every 6 months for the first 2 years for recurrence. They further issued an evidence-based recommendation that patients receive annual imaging to detect new primary lung cancers after 2 years.
Diagnostic chest CT, including the adrenals and preferably with contrast, was recommended as the optimal imaging modality for the first 2 years of surveillance. The panel made this recommendation with a qualifying statement: “There is no evidence of added benefit for a CT of the abdomen and pelvis over a chest CT through the adrenals as a surveillance imaging modality for recurrence.”
The recommended imaging modality to detect new primary lung cancers after the first 2 years was low-dose screening chest CT. The panel cautioned against using 18F-labeled fluorodeoxyglucose positron emission tomography as a surveillance tool.
The panel advised that age should not preclude surveillance, but that surveillance should not be recommended to patients who are unwilling or unable to undergo further treatment. They also recommended that practitioners not use circulating biomarkers to detect recurrence in patients who received curative-intent therapy.
The use of brain MRI was not recommended as a surveillance strategy for patients with stage I-III NSCLC. However, for patients with stage I-III SCLC whose curative-intent surgery did not include prophylactic cranial irradiation, the panel recommended brain MRI every 3 months for the first year after treatment and every 6 months for the second year.
This recommendation came with a qualifying statement: “Brain MRI should not be routinely offered to asymptomatic patients after 2 years of disease-free survival.”
The experts cautioned that their recommendations were only applicable to patients with stage I-III NSCLC or SCLC who received curative-intent therapy, and should not be considered applicable to all patients with lung cancer.
