Key Points
- Although patients with localized non-small cell lung cancer (NSCLC) or small cell lung cancer (SCLC) are treated with intent to cure, the optimal surveillance of these patients for cancer recurrence and new primary lung cancers after potentially curative therapy is controversial.
Non-Small Cell Lung Cancer
- The chance of NSCLC recurrence is greatest during the first 2 years following treatment with curative intent.
- Patients with an intrathoracic recurrence may be salvaged with surgical resection, stereotactic body radiotherapy (SBRT) or chemoradiation depending on the clinical scenario.
- Early identification of extra-thoracic metastatic recurrence may allow prompt molecular testing and facilitate the safe administration of precision palliative therapy before patients develop severe symptoms or deteriorate.
- Two or more years after curative intent therapy, patients are at higher risk of developing a second primary lung cancer (1.5-2% per year) and may benefit from screening.
Small Cell Lung Cancer
- During the first year after initial chemoradiation for SCLC, approximately 40% of patients with stage I-III (limited stage) will relapse. This increases to 60% during the 3 years post-treatment.
- The risk of intracranial recurrence is significant. Therefore, close central nervous system (CNS) surveillance may afford treatment before permanent neurologic sequelae develop from symptomatic SCLC brain metastases.
Recommendations
NOTE:
- These recommendations apply to patients with curatively treated stage I-III NSCLC and SCLC with no clinical suspicion of recurrent disease. This includes patients treated with surgery, stereotactic body radiotherapy and chemoradiation. Please refer to the recommendation discussion section for further details on specific patient subpopulations.
- These recommendations pertain only to routine surveillance strategies. Imaging to evaluate symptoms and follow-up on previous findings are not addressed by this guideline.
- These recommendations do not address the frequency of the clinical evaluation (history and physical exam) for either the suspicion of recurrence and/or to provide reassurance.
- Patients should undergo surveillance imaging for recurrence every 6 months for 2 years. (Moderate Recommendation; IC-L)
- Patients should undergo surveillance imaging for detection of new primary lung cancers annually after the first 2 years. (Moderate Recommendation; EB-I)
- Clinicians should use a diagnostic chest CT that includes the adrenals, with contrast (preferred) or without contrast when conducting surveillance for recurrence during the first two years post-treatment. (Moderate Recommendation; IC-L)
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.
- Clinicians should use a low dose screening chest CT when conducting surveillance for new lung primaries after the first two years post-treatment. (Moderate Recommendation; IC-L)
- Clinicians should NOT use FDG-PET/CT as a surveillance tool. (Moderate Recommendation; IC-L)
- 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.(Weak Recommendation; IC-L).
- Clinicians should NOT use circulating biomarkers as a surveillance strategy for detection of recurrence in patients who have undergone curative intent treatment for stage I-III NSCLC or SCLC. (Moderate Recommendation; IC-I)
- For stage I-III NSCLC patients, clinicians should not use brain MRI for routine surveillance for recurrence in patients who have undergone curative intent treatment. (Moderate Recommendation; IC-L)
- In patients who have undergone curative intent treatment for stage I-III SCLC and did not receive prophylactic cranial irradiation (PCI), clinicians should offer brain MRI every 3-months for the first year and every 6 months for the second year for surveillance. The same schedule may be offered for patients who did receive PCI. (Weak Recommendation; IC-L)
Qualifying statement. Brain MRI should not be routinely offered to asymptomatic patients after 2 years of disease-free survival.
