Best imaging modality for postresection NSCLC follow-up yet to be determined
CT-based surveillance, recommended by major international guidelines during the first 2 years after complete resection of non-small-cell lung cancer (NSCLC), has demonstrated no significant overall survival (OS) benefit over less intensive surveillance with clinical examinations and chest X-rays (CXR) only, according to a study presented at the European Society for Medical Oncology (ESMO) 2017 Congress in Madrid, Spain.
However, CT-based surveillance may have potential long-term benefit in patients at high risk of second primary cancers (SPC), results of the study have shown. [ESMO 2017, abstract 1273O]
The IFCT-0302 study – the first large, randomized, controlled trial on postresection NSCLC follow-up – included 1,775 patients (median age, 63 years; 75.3 percent male) who underwent complete resection for stage I, II or IIIA NSCLC. The patients were followed up every 6 months for 2 years, and then once a year for 5 years. Patients in the control arm received minimal follow-up with clinical examination and CXR, while those in the experimental arm underwent additional thoraco-abdominal CT scanning, as well as mandatory fibreoptic bronchoscopy for squamous and large-cell carcinoma.
After a median follow-up of 8.7 years, OS between the two groups did not differ significantly (median OS for maximum vs minimum surveillance, 123.6 vs 99.7 months, p=0.27; OS rate, 54.6 vs 51.7 percent).
“As such, our suggestion for practice is that both follow-up protocols are acceptable,” said lead author Dr Virginie Westeel of Hôpital Jean Minjoz, France. “CT scanning every 6 months is probably of no value in the first 2 years, but maintaining yearly chest CT scans might be of benefit over the long term.”
While intensive follow-up offered no survival benefit among patients with recurrence or SPC at 24 months (median OS, 48.3 months vs 48.4 months for minimal follow-up, p=0.34), significant survival benefit was found among patients who did not have recurrence or SPC in the first 24 months (median OS, not reached vs 129.3 months for minimal follow-up; p=0.04).
“Patients without recurrence in the first 2 years of follow-up had higher risk of SPC than recurrence, and the SPC may be more amenable to curative treatment. These patients therefore benefit from CT scans, which allow earlier detection of the SPC,” explained Westeel.
“CXR cannot detect distant metastases which are most likely to occur in the first year after resection. Furthermore, CXR are less sensitive than CT scan in identifying SPC. More intensive follow-up is therefore logical,” remarked discussant Dr Egbert Smit of the Netherlands Cancer Institute, Amsterdam, the Netherlands. [ERS 2015, abstract 264]
“Current guideline recommendations on follow-up of resected NSCLC differ markedly, ranging from CT scan every 6 months in the first 2 years postresection [ESMO 2017] to CT scan not being required at all [The Netherland Pulmonary Physician Society Congress 2015], and the level of evidence is low. This is why the IFCT-0302 study is so important,” Smit noted.
“Nevertheless, additional data are still required to support abandoning CT-based surveillance, especially during the first 2 years after NSCLC resection, as previous studies have suggested that CT scan is associated with survival benefit. Studies evaluating the cost-effectiveness of CT- based surveillance could also be done,” concluded Smit.