From the Guidelines
Patients with non-small cell lung cancer (NSCLC) should undergo surveillance imaging every 6 months for the first 2 years after treatment, and then annually, to detect new primary lung cancers and recurrence, with chest computed tomography (CT) imaging being the optimal modality for surveillance. This recommendation is based on the most recent and highest quality study, which suggests that this surveillance strategy can detect approximately 90% of second primary cancers and almost two-thirds of both distant and locoregional recurrences over the median 3-year follow-up 1. The use of chest CT scan with contrast is preferred due to its superior sensitivity for detecting recurrence compared to chest X-rays.
Some key points to consider in the surveillance of NSCLC patients include:
- The frequency of surveillance imaging may be tailored to individual patient factors, such as the stage of disease and the presence of comorbidities 1.
- Brain MRI may be added for patients with stage III disease or those with adenocarcinoma histology due to higher risk of brain metastases, but its routine use is not recommended for surveillance in stage I-III NSCLC 1.
- PET-CT is not routinely recommended for surveillance but may be useful when there are equivocal findings on CT 1.
- Symptoms should prompt immediate evaluation regardless of the scheduled surveillance interval.
It is essential to balance the benefits of surveillance imaging with the potential risks, including radiation exposure and healthcare costs. The goal of surveillance is to identify potentially treatable recurrences or second primary lung cancers at an earlier, more manageable stage, which may improve outcomes for some patients. However, the evidence suggests that more frequent imaging does not necessarily translate into a survival benefit, and the optimal surveillance strategy may vary depending on individual patient factors and disease characteristics 1.
From the Research
Imaging Frequency in Adjuvant Setting for NSCLC
The recommended frequency for imaging in the adjuvant setting for non-small cell lung cancer (NSCLC) is as follows:
- CT imaging is recommended at months 3,6, and 12 in year 1 and then every 6 months in year 2 and annually in years 3 through 5 2
- After 5 years, CT imaging should continue, although no consensus was reached regarding the frequency 2
- There is limited evidence to guide routine use of fludeoxyglucose positron emission tomography/CT, but it is strongly recommended if there is a suspicion for local recurrence 2
Comparison of Imaging Methods
Studies have compared the performance of different imaging methods for follow-up of lung cancer treatment:
- A randomized pilot study compared integrated 18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) and contrast-enhanced computed tomography (CE-CT) and found that PET-CT is not superior to CE-CT in detecting cancer recurrence during 2 years after curative-intent treatment of NSCLC 3
- The sensitivity, specificity, and positive predictive value for detecting cancer recurrence were calculated for both imaging procedures, with CE-CT showing slightly better results 3
General Recommendations
General recommendations for the management of NSCLC include:
- Accurate staging of the cancer to determine the optimal management strategy, which includes surgery, radiochemotherapy, immunotherapy, and targeted approaches 4
- The use of expert multidisciplinary teams to determine optimal management for patients with localized, mediastinal lymph node-negative NSCLC 5
- The consideration of adjuvant therapies, such as cisplatin-based postoperative chemotherapy, targeted therapies, and immune checkpoint inhibitors, for patients with stage II-III NSCLC who underwent complete resection 6