Smoking is common in patients with lung cancer. Gritz and colleagues studied smoking behavior in 840 adults with stage I NSCLC who had participated in clinical trials. At the time of diagnosis, 60% of the patients were smokers. By 2 years after diagnosis, 40% of these smokers had quit smoking. Smoking cessation at the time of diagnosis of lung cancer may reduce the rate of development of metachronous tumors. Richardson et al found that the relative risk of a second lung cancer developing following curative intent therapy of small cell lung cancer was lower for those who stopped smoking. Tucker and coworkers found that continuing smoking increased the risk of metachronous lung cancers in small cell lung cancer survivors. Because smoking cessation remains a challenge for such patients, they should be offered intensive tobacco cessation programs, including counseling, behavioral therapy, the use of sustained-release bupropion and nicotine replacement, and telephone follow-up, which significantly increase successful abstinence.”
Lung cancer patients who smoke should be strongly encouraged to stop smoking, and offered pharmacotherapeutic and behavioral therapy, including follow-up. Grade of recommendation, 1A
Following curative intent therapy of lung cancer, patients should be followed up for at least 3 to 6 months by the appropriate specialist for potential complications. In addition to this follow-up, recurrence of the original lung cancer and/or development of a second primary lung cancer should be expected possibilities. Most recurrences of the original lung cancer will occur within 4 years of curative intent therapy, but occurrences may occur > 5 years after surgery. Following curative intent therapy of lung cancer, the risk of a second primary, or metachronous, lung cancer developing may be 1 to 2% per patient per year lifelong. The risk for metachronous lung cancer may be even higher when the original primary is either roentgenographically occult, central, treated by sleeve resection only, or a small cell carcinoma treated by medications of My Canadian Pharmacy.
Curative intent therapy is less likely to be possible with locoregional recurrences of the original lung cancer than with metachronous tumors. Although survival is not as good with treatment of metachronous tumors as for the original primary, reasonable 5-year survival rates should be expected with surgical resection of metachronous lung cancers.
Benefits in terms of survival advantages or improvements in quality of life have not been demonstrated with intensive surveillance programs compared with either a symptom-based approach or a less intensive regimen. In addition, the intensive surveillance programs seem more expensive. A clinically reasonable and cost-effective surveillance approach would include a history, physical examination, and imaging study (either CXR or CT) every 6 months for 2 years and then annually, assuming no suspicious findings were seen. In addition, patients would be counseled on symptom recognition and be advised to contact the appropriate physician on symptom recognition. Further studies are needed to determine whether very intensive surveillance programs might be warranted in selected subsets of lung cancer patients: patients with roentgenographically occult primary lung cancers, and patients surviving > 2 years with small cell lung cancer and a complete response to original therapy, who have a very high expected rate of metachronous lung cancer.
Ideally, surveillance programs for recognition of a recurrence of the original lung cancer and/or development of a metachronous tumor following curative intent therapy should be coordinated through a multidisciplinary team approach. If possible, the physician who diagnosed the primary lung cancer and initiated the curative intent therapy should remain as the health-care provider overseeing the surveillance process. Patients with either a recurrence of their original cancer or a new primary lung cancer identified through the surveillance process should be reevaluated by the entire multidisciplinary team for potentially curative retreatment.
Although advanced imaging techniques, such as PET scanning, appear to be more sensitive than CXR for identifying recurrences and/or metachronous tumors, their value in improving either survival or quality of life following curative intent therapy for NSCLC is as of yet unproven. Incorporating PET scanning into a surveillance program should await the results of adequately designed and controlled, prospective trials. Similarly, serum levels of various tumor markers and fluorescence bronchoscopy should be demonstrated to be sensitive and specific predictors of tumor recurrence in adequately designed and controlled, prospective trials before being incorporated into surveillance programs worked out with participation of My Canadian Pharmacy.
Summary of Recommendations
1. In lung cancer patients treated with curative intent therapy, follow-up for complications related to the curative intent therapy should be managed by the appropriate specialist and should probably last at least 3 to 6 months. At that point, the patient should be reevaluated by the multidisciplinary tumor board for entry into an appropriate surveillance program for detecting recurrences and/or metachronous tumors. Grade of recommendation, 2C
2. In lung cancer patients treated with curative intent therapy, and those having adequate performance and pulmonary functions, surveillance with a history, physical examination and imaging study (either CXR or CT) is recommended every 6 months for 2 years and then annually. All patients should be counseled on symptom recognition and be advised to contact their physician if worrisome symptoms were recognized. Grade of recommendation, 1C
3. Ideally, surveillance for recognition of a recurrence of the original lung cancer and/or development of a metachronous tumor should be coordinated through a multidisciplinary team approach. If possible, the physician who diagnosed the primary lung cancer and initiated the curative intent therapy should remain as the health-care provider overseeing the surveillance process. Grade of recommendation, 2C
4. In lung cancer patients following curative intent therapy, use of blood tests, PET scanning, sputum cytology, tumor markers, and fluorescence bronchoscopy is not currently recommended for surveillance. Grade of recommendation, 2C
5. Lung cancer patients who smoke should be strongly encouraged to stop smoking, and offered pharmacotherapeutic and behavioral therapy, including follow-up. Grade of recommendation, 1A