What is the NCCN (National Comprehensive Cancer Network) guideline for surveillance in early stage lung cancer patients who have completed XRT (External Beam Radiation Therapy) and chemotherapy?

NCCN Surveillance Guidelines for Early Stage Lung Cancer After XRT and Chemotherapy

For early stage lung cancer patients who have completed XRT and chemotherapy, surveillance should include physical examination and contrast-enhanced chest CT every 6 months for 2-3 years, then annually thereafter, coordinated by a multidisciplinary team. 1

Surveillance Schedule

First 2-3 Years

• Clinical visits every 6 months including:
  • Complete history
  • Physical examination
  • Contrast-enhanced chest CT scan 1, 2

After 2-3 Years

• Annual visits including:
  • History
  • Physical examination
  • Chest CT scan 1, 2

Rationale for Surveillance

Surveillance is critical for:

1. Monitoring treatment-related complications (especially during first 3-6 months)
2. Early detection of treatable recurrence
3. Identification of second primary lung cancers 1

Important Considerations

Imaging Recommendations

• Contrast-enhanced CT is preferred over non-contrast CT 2
• PET-CT is NOT recommended for routine surveillance 1
• PET-CT should only be used selectively when recurrence is suspected based on serial CT findings 1, 2
• Chest X-ray alone is insufficient for adequate surveillance 2

Post-SABR Considerations

• Radiation-induced lung changes on CT are common after SABR (54-79% early changes, 80-100% late changes) and can mimic recurrence 2
• If recurrence is suspected after SABR:
  • Consider PET-CT (SUV max above 5 at ≥6 months post-SABR suggests high risk of local recurrence) 2
  • Biopsy is strongly recommended before salvage therapy due to high false-positive rates on PET 1, 2

Disease Recurrence Patterns

• Local recurrence risk is highest in the first 2 years 2
• Second primary lung cancers increase from 1% to 3% per patient per year during the first 3 years and continue long-term 2

Additional Recommendations

• Smoking cessation should be offered to all patients as it leads to superior treatment outcomes 1
• Combining behavioral techniques with pharmacotherapy is the preferred approach for smoking cessation 1
• The frequency of follow-up visits can be tailored for patients not suitable for salvage treatment 1

Caveats and Pitfalls

• Despite better sensitivity for recurrence detection, routine PET-CT surveillance has not demonstrated survival benefit and is therefore not recommended 2
• New pulmonary nodules should prompt workup for potential new primary cancer 1
• When evaluating potential recurrence, biopsy is essential before initiating salvage therapy due to high false-positive rates on imaging 1

This surveillance protocol aligns with NCCN and ESMO guidelines, focusing on detecting recurrences and second primary tumors when intervention would still be beneficial for patient outcomes.