Lung Cancer Follow Up

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-II NSCLC given primary treatment including surgery with or without 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.  

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.