Lung Cancer Surveillance After Definitive Curative-Intent Therapy Guideline

An interview with Dr. Benjamin Levy from Johns Hopkins Sidney Kimmel Cancer Center at Sibley Memorial Hospital on “Lung Surveillance After Definitive Curative-Intent Therapy: ASCO Guideline.” This guideline provides recommendations to clinicians on radiographic imaging and biomarker surveillance strategies after definitive curative-intent therapy in patients with stage I-III non–small-cell lung cancer and small-cell lung cancer. Read the full guideline at www.asco.org/thoracic-cancer-guidelines   Transcript Hi. My name is Clifford Hudis, and I am the CEO of the American Society of Clinical Oncology, as well as the host of the ASCO in Action podcast. About twice a month, I interview thought leaders in health care and experts in oncology, and we provide analysis and commentary on a wide range of cancer policy and practice issues. You can find the ASCO in Action podcast on Apple Podcasts or wherever you are listening to this show, and you can find all nine of ASCO's podcasts which cover a wide range of educational and scientific content, and offer enriching insight into the world of cancer care at podcast.asco.org.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Hello and welcome to the ASCO Guidelines podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at podcast.asco.org. My name is Brittany Harvey, and today I'm interviewing Dr. Benjamin Levy from Johns Hopkins Sidney Kimmel Cancer Center at Sibley Memorial Hospital, author on "Lung Surveillance After Definitive Curative Intent Therapy ASCO Guideline." Thank you for being here, Dr. Levy.   Thanks for having me.   So first, can you give us a general overview of what this guideline covers?   Yeah, I think that the general broad stroke intent of this consensus paper was to provide evidence-based guidelines and recommendations for practicing clinicians on what the optimal radiographic imaging and biomarker surveillance strategy should be for patients who received definitive curative intent therapy, and specifically for patients with stage I through III non-small-cell lung cancer, or patients who have received curative intent therapy for a limited-stage small-cell lung cancer.   And importantly, this expert panel comprised a multidisciplinary team, and this included not only medical oncologists, but surgical oncologists, pulmonologists, radiologists, a general internist, a patient representative. So we had, I think, the relevant stakeholders to make the best recommendations we could based on the evidence. And we really framed our recommendations by answering five questions, and I think we can get to the five questions at a later time during this cast, but we try to answer these five questions in a systematic way. And really looked at the type-- was an evidence-based or was it informal consensus? What was the evidence quality? Was it low, was it intermediate, or was it high? And then finally, the strength of the recommendation.   And importantly, we tried to answer these questions based on the evidence. We did a literature search, which culminated in a systematic review of more than-- close to 1,200 studies of which 14 studies were identified, and these 14 studies included meta-analysis, randomized control trials, case-controlled trials, and retrospective studies, and really by doing this, we wanted to come up with important guidelines. I think these guidelines are coming on the heels of a lot of confusion about what is the optimal surveillance strategies post-curative intent therapy for our lung cancer patients? So we recognize this confusion and tried our best to create guidelines that were reasonable to follow, and hopefully it can change practice.   Great. So you just mentioned that there were five key questions that you looked at for this guideline.   Yeah.   Could you elaborate on what those questions are and the key recommendations of the guideline?   Sure. So the crux of our recommendations, again, come on these five questions, and just a summary of these questions. One, what should be the frequency of surveillance imaging post-curative intent therapy? Two, what is the optimal imaging modality? Three, are there any patient factors such as performance status or age limits that would preclude surveillance? Four, is there a role for circulating biomarkers and surveillance? And then five, is there-- or what is the role of brain MRI imaging for surveillance of curative intent patients both non-small cell and small-cell?   And just briefly in terms of-- I'll maybe go over briefly just the answers to these questions that we tried to hash out in this consensus work-- for the question, what should be the frequency of surveillance imaging? We recommended that patients should undergo surveillance imaging for recurrence every six months for two years. We then recommend that patients should undergo surveillance imaging for detection of new primary lung cancers annually after the first two years.   And in question 2, what is the optimal imaging modality? We recommended a diagnostic chest CT that included the adrenals with contrast, that's preferred, or without contrast when conducting surveillance for recurrence during the first two years post-treatment. We did state that there was no evidence of any added benefit for CT of the abdomen and pelvis over a chest CT through the adrenals, that surveillance. We then, again, similar answer to recommendation 1, we do recommend a low dose screening for chest CT when conducting surveillance for new lung primaries after those first two years. And then I think importantly, we take a hard stand on PET scans as part of the answer to question 2, where we really should not be using PET scans as a surveillance tool in the surveillance starting post-curative intent therapy.   Question 3, are there any patient factors such as performance status or age limits that would preclude surveillance? And for us, we make the recommendation that surveillance imaging may be permitted in some patients who are clinically unsuitable, have multiple medical comorbidities, or unwilling to undergo further treatment. Doesn't make a lot of sense to offer surveillance imaging if patients are stating that they're not going to undergo any further treatment. We also state that age should not preclude surveillance imaging, but there needs to be a consideration for overall health status and chronic medical conditions and patient preferences.   Question 4 was, is there a role for circulating biomarkers in surveillance? And this is probably one of the more confusing parts of surveillance. Many physicians are still using CEA to monitor for a recurrence, and we really take a hard stand and say that clinicians should not be using circulating biomarkers as surveillance strategy for the detection of recurrence in patients who've undergone curative intent treatment, but we also do state that there is emerging data looking at ctDNA that may change this over the next four or five years, but we're certainly not there yet. So standard of care should not be-- to be using anything like that.   And then question 5 is, are there-- or what is the role for brain MRI for surveillance in patients with both non-small-cell and small-cell? And our recommendations are a little nuanced here. We did say for patients with stage I through III non-small-cell lung cancer, clinicians should not be using a brain MRI for routine surveillance after curative intent therapy, and patients who have undergone curative intent treatment for small-cell and did not receive prophylactic cranial radiation, this is where we do say clinicians should offer a brain MRI every three months for the first year and then every six months for the second year for surveillance. So a little bit different surveillance strategies for patients whether you're small-cell or non-small-cell.   So those are the broad stroke overviews of the recommendations that we put together in this consensus statement.   And then can you speak to the importance of this guideline and these recommendations and how they will impact practice?   I think that ASCO recognized how much confusion there was post-curative intent therapy. So I think this is the reason why these guidelines are so important. We need to keep in mind that health care resources that are utilized and be mindful of that. There's no real role for routine imaging less than the intervals that we're describing as they may obviously not be in touch with health care utilization and cost.   The other thing is this idea that patients are getting scans so frequently that we're picking up on a lot of false positive information that can't be used, and so we recognize that as well. So I think that on the heels of the confusion coupled with cost considerations, as well as what we're picking up on frequent scans, we do have to make recommendations that will hopefully unify and harmonize practice across the country to better suit patients and also evidence-based practice. I think that's really important.   And finally, how will these guideline recommendations affect patients?   Yeah, I think patients hopefully, if physicians follow these guidelines, will be receiving the appropriate interval. I mean, look, we understand that two-thirds of patients with lung cancer who relapse will present with metastatic disease and that there have been limited data thus far on what should be the optimal interval for scans. But we understand also that patients who do relapse could present with potentially curable lung cancer, and in addition, there's been recent data to suggest that even patients with limited metastatic disease who was detected on recurrence may be cured or may have improved survival with certain strategies like local ablative therapy.   So we hope that these guidelines can be firmly cemented into the practice for clinicians so that the appropriate interval is selected, but that also patients can benefit from these appropriately timed-out scans to improve outcomes for them.   Great. Thank you for your work on these guidelines, and thank you for taking the time today to give an overview to our listeners, Dr. Levy.   Thank you so much.   And thank you to all of our listeners for tuning into the ASCO Guidelines podcast series. To read the full guideline, go to www.asco.org/thoracic-cancer-guidelines. 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