Imaging surveillance and survival for surgically resected non–small-cell lung cancer

doi:10.1016/j.jss.2015.06.048

Journal of Surgical Research

Volume 200, Issue 1, January 2016, Pages 171-176

https://doi.org/10.1016/j.jss.2015.06.048 Get rights and content

Abstract

Introduction

The importance of imaging surveillance after treatment for lung cancer is not well characterized. We examined the association between initial guideline recommended imaging surveillance and survival among early-stage resected non–small-cell lung cancer (NSCLC) patients.

Methods

A retrospective study was conducted using Surveillance, Epidemiology, and End Results–Medicare data (1995–2010). Surgically resected patients, with stage I and II NSCLC, were categorized by imaging received during the initial surveillance period (4–8 mo) after surgery. Primary outcome was overall survival. Secondary treatment interventions were examined as intermediary outcomes.

Results

Most (88%) patients had at least one outpatient clinic visit, and 24% received an initial computerized tomography (CT) during the first surveillance period. Five-year survival by initial surveillance imaging was 61% for CT, 58% for chest radiography, and 60% for no imaging. After adjustment, initial CT was not associated with improved overall survival (hazard ratio [HR], 1.04; 95% confidence interval [CI] 0.96–1.14). On subgroup analysis, restricted to patients with demonstrated initial postoperative follow-up, CT was associated with a lower overall risk of death for stage I patients (HR, 0.85; 95% CI, 0.74–0.98), but not for stage II (HR, 1.01; 95% CI, 0.71–1.42). There was no significant difference in rates of secondary interventions predicted by type of initial imaging surveillance.

Conclusions

Initial surveillance CT is not associated with improved overall or lung cancer –specific survival among early-stage NSCLC patients undergoing surgical resection. Stage I patients with early follow-up may represent a subpopulation that benefits from initial surveillance although this may be influenced by healthy patient selection bias.

Introduction

Despite advances in treatment and early detection, patients undergoing definitive treatment for non–small-cell lung cancer (NSCLC) remain at risk for recurrence or second primary lung cancers (SPLCs). The risk is estimated at 2%–3% per patient-year for recurrence and 1%–4% per patient-year for SPLC [1], [2], [3], [4], [5]. As such, many international guidelines have advocated for routine surveillance for treated patients [6], [7], [8], [9]. Although there are inconsistencies, most guidelines recommend more frequent imaging within the first 2 years and favor surveillance with computerized tomography (CT) over chest radiography (CXR). The National Comprehensive Cancer Network (NCCN) guidelines are some of the most widely referenced guidelines and currently recommend surveillance CT at 6- to 12-mo intervals [8].

Our prior work examining rates of recommended imaging surveillance found marked heterogeneity with relatively poor rates of adherence overall. Using the NCCN guidelines in place between 1995 and 2010, we found that only 24% of patients received CT as their initial examination in the first surveillance period [10]. One potential explanation for the low observed adherence rate is the relative lack of high-quality studies substantiating the benefit of surveillance toward improving lung cancer outcomes. Several small studies have suggested that intense surveillance is associated with increased secondary treatment interventions leading to improved survival. These studies serve as the basis for the consensus opinion of the NCCN. In this study, we sought to determine if receipt of initial surveillance imaging is associated with improved survival among a large national cohort of early-stage NSCLC patients undergoing surgical resection.

Section snippets

Data source

We used data from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program from all registries representing a nonrandom sample of 28% of the US population. SEER data were linked to Medicare claims for outpatient clinic visit, imaging, and procedures after surgical treatment for all NSCLC patients between 1995 and 2009 with follow-up through 2010.

Study cohort

A total of 438,872 patients were identified with NSCLC. We limited the analysis to patients with stage I or II disease

Results

Most patients (88%) were seen in an outpatient clinic visit between 4 and 8 mo after surgical resection (Table 1). A total of 24% of patients received a CT as their initial imaging. Five-year survival was 58.8% for the main cohort. Survival was lowest among patients receiving CXR (57.9% [95% CI, 56.9%–59.0%]) or positron emission tomography/CT (PET/CT) (53.0% [95% CI, 47.5%–59.2%]) as their initial imaging (Table 2). Initial CT was not associated with a significant difference in 5-y survival

Discussion

We found no survival benefit associated with receipt of CT during the initial surveillance period of 4-8 mo compared with those receiving no imaging. Other studies have reported mixed results on the association between intensive follow-up and improved survival. In a meta-analysis examining the effect of intense surveillance on survival among NSCLC patients, investigators identified only nine studies meeting rigorous inclusion criteria, but found a nonsignificant trend for intensive follow-up

Conclusions

Despite its limitations, our data suggest that stage I patients may represent a subset of for which routine imaging surveillance may provide survival benefit. Future investigation should couple these population-based observations with evolving techniques such as the use of biomarkers to develop personalized risk prediction models that may be more cost effective with little lost in terms of potential impact on long-term outcomes.

Acknowledgment

Funded by NIH/NCATS National Center for Research Resources 2 KL2 TR000421-06 KL2 Scholar ITHS Multidisciplinary Clinical Research Training Program. Views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Authors' contributions: L.M.B., F.F., H.H., T.K.V., D.H.A., D.R.F., and S.B.Z. contributed to the study design; L.M.B., F.F., C.J.L., H.H., D.H.A., D.R.F., and S.B.Z.

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For colorectal and breast cancer, high quality studies do not suggest an impact of intensive follow-up strategies on survival. Colorectal cancer recurrences are more often treated locally after intensive follow-up. For other cancer types evaluated, limited high quality research on follow-up is available.
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For the French translation of the abstract see Supplementary Materials section.
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Oncology/EndocrineImaging surveillance and survival for surgically resected non–small-cell lung cancer

Abstract

Introduction

Methods

Results

Conclusions

Introduction

Section snippets

Data source

Study cohort

Results

Discussion

Conclusions

Acknowledgment

Lung Cancer

Ann Thorac Surg

Chest

Ann Oncol

Chest

Ann Thorac Surg

J Clin Epidemiol

J Thorac Oncol

J Thorac Oncol

Ann Thorac Surg

Ann Thorac Surg

Chest

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Oncology/Endocrine
Imaging surveillance and survival for surgically resected non–small-cell lung cancer