Follow-up and Surveillance of Curatively Treated Lung Cancer Patients
Publication Date: February 4, 2024
Last Updated: February 29, 2024
Summary of Recommendations
Recommendation 1.1
Patients should undergo surveillance imaging for recurrence every six months for two years.
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Recommendation 1.2
Patients should undergo surveillance imaging for detection of new primary lung cancers annually after the first two years.
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Recommendation 2.1
Clinicians should use a diagnostic or low-dose chest computed tomography (CT) that includes the adrenals, without contrast (preferred) or with contrast (when indicated) when conducting surveillance for recurrence during the first two years post treatment.
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.
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Recommendation 2.2
Clinicians should use a low-dose chest CT when conducting surveillance for new lung primaries after the first two years post treatment.
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Recommendation 2.3
Clinicians should not use 18F-labeled fluorodeoxyglucose positron emission tomography as a surveillance tool.
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Recommendation 3
Surveillance imaging may be omitted in patients who are clinically unsuitable for or unwilling to accept further treatment. Age should not preclude surveillance imaging. Consideration of overall health status, chronic medical conditions, and patient preferences is recommended.
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Recommendation 4
Clinicians should not use circulating biomarkers as a surveillance strategy for detection of recurrence in patients who have undergone curative-intent treatment of stage I-III NSCLC or SCLC.
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Recommendation 5.1
For patients with stage I-III NSCLC, clinicians should not perform routine brain surveillance for recurrence with either magnetic resonance imaging (MRI) or CT in patients who have undergone curative-intent treatment.
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Recommendation 5.2
In patients who have undergone curative-intent treatment of stage I-III SCLC and did not receive prophylactic cranial irradiation (PCI), clinicians should offer brain MRI every three months for the first year and every six months for the second year for surveillance. The same schedule may be offered for patients who did receive PCI.
Qualifying statement: Brain MRI should not be routinely offered to asymptomatic patients after two years of diseasefree survival.
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Recommendation 6
In the expert opinion of the authors, any new and persistent or worsening symptom warrants the consideration of a recurrence, especially:
Constitutional symptoms:
• Dysphagia
• Fatigue (new onset)
• Nausea or vomiting (unexplained)
• New finger clubbing
• Suspicious lymphadenopathy
• Sweats (unexplained)
• Thrombotic event
• Weight loss or loss of appetite
Pain:
• Bone pain
• Chest pain
• Caveat shoulder pain not related to trauma
Neurological symptoms:
• Headaches (if persistent)
• New neurological signs suggestive of brain metastases or cord compression such as leg
weakness or speech changes
• Headache or focal neurological symptoms
Respiratory symptoms:
• Cough (despite use of antibiotics)
• Dyspnea
• Hemoptysis
• Hoarseness
• Signs of superior vena cava obstruction
• Stridor
Constitutional symptoms:
• Dysphagia
• Fatigue (new onset)
• Nausea or vomiting (unexplained)
• New finger clubbing
• Suspicious lymphadenopathy
• Sweats (unexplained)
• Thrombotic event
• Weight loss or loss of appetite
Pain:
• Bone pain
• Chest pain
• Caveat shoulder pain not related to trauma
Neurological symptoms:
• Headaches (if persistent)
• New neurological signs suggestive of brain metastases or cord compression such as leg
weakness or speech changes
• Headache or focal neurological symptoms
Respiratory symptoms:
• Cough (despite use of antibiotics)
• Dyspnea
• Hemoptysis
• Hoarseness
• Signs of superior vena cava obstruction
• Stridor
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Recommendation 7
There is insufficient evidence to recommend routine completion of patient-reported outcome tools at home for symptom monitoring or early detection of recurrence.
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Recommendation 8
Health-related quality of life is very important for long-term survivors suffering from late side effects of their curative-intent therapy (including surgery, chemotherapy, and radiation therapy). Symptoms that are frequently experienced by lung cancer survivors include but are not limited to:
Constitutional issues:
• Anxiety
• Cough
• Decline in appetite
• Decrease in general health
• Depression
• Dysphagia
• Fatigue
• Fear of cancer recurrence
• Pain
• Physical ability restrictions
• Reduced sleep quality
• Shortness of breath
Long-term systemic therapy effects:
• Hearing loss
• Neuropathies
• Renal impairment
• Delayed immune-related adverse events
• Cumulative toxicities from ongoing therapy with tyrosine kinase inhibitors
Long-term radiation effects:
• Breathing complications
• Breathlessness/dyspnea
Long-term post-surgical effects:
• Empyema
• Oxygen dependence
• Post-thoracotomy pain syndrome
• Reduced exercise tolerance or activity limitations
• Shortness of breath
Patients should be encouraged to discuss these symptoms with their healthcare providers.
Health care professionals need to aid lung cancer survivors in handling these symptoms to improve quality of life.
Constitutional issues:
• Anxiety
• Cough
• Decline in appetite
• Decrease in general health
• Depression
• Dysphagia
• Fatigue
• Fear of cancer recurrence
• Pain
• Physical ability restrictions
• Reduced sleep quality
• Shortness of breath
Long-term systemic therapy effects:
• Hearing loss
• Neuropathies
• Renal impairment
• Delayed immune-related adverse events
• Cumulative toxicities from ongoing therapy with tyrosine kinase inhibitors
Long-term radiation effects:
• Breathing complications
• Breathlessness/dyspnea
Long-term post-surgical effects:
• Empyema
• Oxygen dependence
• Post-thoracotomy pain syndrome
• Reduced exercise tolerance or activity limitations
• Shortness of breath
Patients should be encouraged to discuss these symptoms with their healthcare providers.
Health care professionals need to aid lung cancer survivors in handling these symptoms to improve quality of life.
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Recommendation 9
For lung cancer survivors who have completed curative-intent therapy, surveillance is required and may be provided by specialists, family physicians or nurse-led clinics.
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Recommendation 10
Cancer survivorship considerations during virtual care
• Assess the need for in-person physical examination
• Cancer survivors under surveillance following curative intent treatment can be safely followed using virtual care, unless in-person physical examination is indicated and/or required. Transition to virtual survivorship care
• Primary care providers and cancer survivors should be made aware of the potential for transition to virtual survivorship care.
• Assess the need for in-person physical examination
• Cancer survivors under surveillance following curative intent treatment can be safely followed using virtual care, unless in-person physical examination is indicated and/or required. Transition to virtual survivorship care
• Primary care providers and cancer survivors should be made aware of the potential for transition to virtual survivorship care.
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Recommendation 11
Smoking cessation counselling is recommended for patients who have completed curativeintent therapy for NSCLC and SCLC. Although verbal cessation advice from a healthcare professional is of benefit, interventions that involve behavioural and pharmacotherapy support in addition to verbal advice is recommended.
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Recommendation 12
Adult patients with lung cancer after curative-intent treatment living in Ontario should receive vaccinations as recommended by the Government of Canada [3]. The influenza and pneumococcal vaccine schedules for persons with chronic diseases, which includes cancer, or for immunocompromised persons should be followed. Further information can be found here: Canadian Immunization Guide - Canada.ca. The COVID-19 schedule for adults or immunocompromised persons should followed. Further information can be found here: COVID19 vaccine: Canadian Immunization Guide - Canada.ca.
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Recommendation 13
Enrolling in an exercise or rehabilitation program is recommended.
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Recommendation Grading
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Follow-up and Surveillance of Curatively Treated Lung Cancer Patients
Authoring Organization
Cancer Care Ontario
Publication Month/Year
February 4, 2024
Last Updated Month/Year
March 13, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
CA
Document Objectives
The primary objective of this guideline is to develop recommendations for the optimal management of patients with lung cancer after curative-intent treatment.
Target Patient Population
Adult patients with small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC) after curative-intent treatment
Target Provider Population
Thoracic surgeons, medical and radiation oncologists specializing in lung cancer, radiologists, primary care providers, respirologists, nurses, and psychosocial care providers
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient, Radiology services
Intended Users
Nurse, nurse practitioner, physician, physician assistant, radiology technologist, respiratory therapist
Scope
Counseling, Management
Diseases/Conditions (MeSH)
D008175 - Lung Neoplasms
Keywords
non-small cell lung cancer, NSCLC, Non Small Cell Lung Cancer, small cell lung cancer, small cell lung cancer (SCLC), SCLC
Source Citation
PEBC Report Citation (Vancouver Style): Shargall Y, Vella ET, Del Giudice L, Kulkarni S, Ellis PM, Dennie C, et al. Follow-up and Surveillance of Curatively Treated Patients with Lung Cancer. Toronto (ON): Ontario Health (Cancer Care Ontario); 2024 February 5. Program in Evidence-Based Care Guideline No.: 26-3 Version 2.
Methodology
Number of Source Documents
87
Literature Search Start Date
June 1, 2022
Literature Search End Date
July 20, 2023