Monitoring
NSCLC
Follow-Up After Therapy
Studies have shown a 6.5% annual recurrence rate of NSCLC stage I. For patients with further disease progression
despite switching systemic agents, enrollment into clinical trial and best
supportive care should be considered. Observation for complications of treatment is recommended for at least
3-6 months.
Follow-up
with history, physical examination, and chest CT scan with or without contrast
is advised every 6 months for 2-3 years; then history, physical examination,
and low-dose chest CT scan without contrast annually thereafter for patients with
stage I to II NSCLC given primary treatment including surgery with or without systemic chemotherapy.
The peak incidence of recurrence is between 2 and 3 years.
For patients with stage I-II NSCLC given primary
treatment with RT, and patients diagnosed with stage III or IV NSCLC, history, physical
examination, and chest CT scan with or without contrast is advised every 3-6
months for 3 years; then history, physical examination, and chest CT scan with
or without contrast every 6 months for 2 years, then history and physical
examination with low-dose chest CT scan without contrast annually. More
frequent imaging may be required if there are residual or new radiographic
abnormalities.
For patients with advanced or metastatic disease,
response to initial therapy should be assessed after 2 cycles using CT with or
without contrast on previously identified tumor sites, then every 2-4 cycles or
when clinically indicated. Assessment of response to subsequent therapy should
be done every 6-12 weeks using CT with or without contrast on previously
identified tumor sites.
It is recommended that
all screening and follow-up CT scans should be performed at a dose of 100-120
kVp and 40-60 mAs or less. Biomarkers (eg ALK fusion oncogene, ROS1 gene
rearrangements, BRAF V600E mutations, EGFR mutations, PD-1
ligand) may be utilized to predict treatment outcome or disease prognosis.
Immunizations (coronavirus disease 2019 [COVID-19]
vaccine, pneumococcal vaccine [with revaccination], annual influenza vaccine, hepatitis
vaccine, Herpes zoster vaccine) should also be given.
Patients who smoke should be advised to quit.
Please see Smoking Cessation
disease management chart for further information.
Lung cancer-specific exercise recommendations,
smoking cessations, chronic cancer pain management, psychosocial evaluation and
referrals, financial monitoring and referrals, care coordination with primary
care clinicians and monitoring of cancer-related fatigue should be part of the
long-term follow-up care of patients.
SCLC
Response to primary
treatment is assessed using chest, pelvic, and abdominal CT scan with contrast,
or brain MRI or CT with contrast, CBC, electrolytes, LFTs, BUN, and creatinine
levels, depending on previous treatment given and the stage of the patient's
disease.
Patients with limited
disease are advised to follow up every 3 months for the first year or two, then
every 6 months during the third year, then annually after recovery. Patients with
extensive disease are advised to follow up every 2 months during the first
year, then every 3-4 months on years 2-3, then every 6 months on years 4-5,
then annually. Brain MRI, which is preferred, or CT scan with contrast every 3-4
months during the first year, then every 6 months afterwards then as clinically
indicated, regardless of PCI status is recommended. FDG-PET/CT is not
recommended for routine follow-up unless contrast CT of the chest, abdomen, and
pelvis is contraindicated.
It is recommended that
all screening and follow-up CT scans should be performed at a dose of 100-120
kVp and 40-60 mAs or less.
Timing of response assessment depends on previous
treatment given and the stage of the patient's disease and are as follows:
- Limited disease SCLC patients given adjuvant chemotherapy or chemoradiotherapy: Only after completion of treatments
- Limited disease SCLC patients given systemic therapy or chemoradiotherapy: After every 2 cycles of systemic therapy and at completion of treatments
- Limited disease SCLC patients given systemic therapy alone or sequential systemic therapy followed by RT: After every 2-3 cycles of systemic therapy and at completion of therapy
- Extensive disease SCLC patients given systemic therapy: After every 2-3 cycles of systemic therapy and at completion of therapy
Response assessment of extensive disease SCLC patients with asymptomatic brain metastasis receiving systemic therapy prior to WBRT should undergo brain MRI or CT scan with contrast every 2 cycles of chemotherapy and after completion of therapy.