FOLLOW UP OF TREATED NON-SMALL CELL LUNG CANCER PATIENTS

Transcription

1 FOLLOW UP OF TREATED NON-SMALL CELL LUNG CANCER PATIENTS THE ART AND THE SCIENCE GIOVANNI BATTISTA MORGAGNI ITALIAN ANATOMIST FATHER OF PATHOLOGIC ANATOMY 1 ST DESCRIPTION OF LUNG CANCER IN

2 INCIDENCE st LUNG CANCER DESCRIBED CASES HAD BEEN REPORTED 1930 ~ 6140 US LUNG CANCER DEATHS SURGERY NO LUNG CANCER SURGERY SURVIVORS SIX LOBECTOMY SURVIVORS 2

3 EVARTS A GRAHAM ST SUCCESSFUL PNEUMONECTOMY FOR LUNG CANCER DIED OF LUNG CANCER 1 ST PATIENT ALIVE IN 1957 RADIATION THERAPY 1903 SKIN CANCER 1922 DAILY DOSES (EXTERNAL BEAM) FOR DEEP SEATED CANCERS 3

4 ARTHUR TUDOR EDWARDS LOBECTOMY FOR LUNG CANCER 1931 TREATED PATIENTS WITH RADON SEEDS & RADIUM PLAQUES RADIATION THERAPY 1970 ADVANCED LOCAL DISEASE HIGHER DOSES PROVIDED SLIGHT IMPROVEMENT IN 2 YR SURVIVAL NO ADDITIONAL EFFECTIVE THERAPY AVAILABLE 4

5 RADIATION THERAPY FOR STAGE I DISEASE 2010 STEREOTACTIC BODY RADIATION AT 2.5 YEARS 4% LOCAL RECURRENCE 72 % 30 MONTH SURVIVAL CURATIVE POTENTIAL STAGE I DISEASE 23% OF PATIENTS POTENTIALLY CURABLE WITH LOCAL THERAPY 77% NEED SYSTEMIC THERAPY TO IMPROVE OUTCOME 5

6 SULFUR MUSTARD FIRST ANTI- CANCER DRUG CHEMICAL WARFARE AGENT WWI 1931 CLINICAL TRIAL CAUSED LEUKOPENIA NITROGEN MUSTARD WW II CHEMICAL WARFARE AGENT LYMPHOMA IN ANIMAL MODELS RESPONDED DRAMATICALLY 1942 FIRST USED CLINICALLY MILITARY SECRET UNTIL

7 CHEMOTHERAPY FOR LUNG CANCER NO RESPONSE % RESPONSE, NO SURVIVAL OR LIFE QUALITY BENEFIT CHEMOTHERAPY TODAY LATE STAGE: SURVIVAL IMPROVED TO 12 MONTHS EARLY STAGE: WHEN ADDED TO SURGERY IMPROVES PROGRESSION FREE & OVERALL SURVIVAL 7

8 THERAPY TODAY EARLY STAGE 30-60% 5 YEAR SURVIVAL LOCALLY ADVANCED ~ 25% 5 YEAR SURVIVAL ADVANCED ~ 12 MONTH SURVIVAL IF RELAPSE AFTER TREATMENT SALVAGE THERAPY WITH POTENTIAL BENEFIT IS AVAILABLE FOR MOST FIT PATIENTS 8

9 OUR QUESTIONS DOES A BENEFIT (INCREASED SURVIVAL AND/OR BETTER LIFE QUALITY) RESULT IF RELAPSE IS DETECTED EARLY? IF SO DOES CLOSE FOLLOW UP AFTER TREATMENT DETECT EARLY RELAPSE? 9

10 THE EVIDENCE 4 PUBLISHED STUDIES RETROSPECTIVE 1 PROSPECTIVE HOUSTON STUDY FOLLOW-UP REGIMEN PHYSICIAN DEPENDANT 358 PATIENTS 38% RELAPSED 102 SYMPTOMATIC 33 ASYMPTOMATIC 10

11 N = 33 ASYMPTOMATIC RELAPSE DETECTION 26 CHEST X-RAY (79%) 2 PHYSICAL EXAM (6%) 1 BRAIN MRI 2 ABDOMINAL CT 1 CHEST CT 1 MULTIPLE MODALITIES RELAPSE DETECTION HISTORY 1O2 PHYSICAL EXAM 2 CHEST X-RAY 26 TOTAL 130 = 96% 11

12 SALVAGE THERAPY 1/3 ASYMPTOMATIC AND 1/3 SYMPTOMATIC RECURRENCES TREATED WITH CURATIVE INTENT BENEFIT FROM SCHEDULED FOLLOW UP LESS THAN 3 % OF ALL PATIENTS WERE RE-TREATED WITH CURATIVE INTENT AS A RESULT OF FOLLOW- UP PROCEDURES 12

13 MEDIAN SURVIVAL OF PATIENTS AT RELAPSE SYMPTOMATIC 8 MONTHS ASYMPTOMATIC MONTHS LEAD TIME BIAS HOSPITAL CHARGES POST SURGERY 62% NO RELAPSE 50% 25% RELAPSED TREATED WITH PALLIATION 30% 13% RELAPSED TREATED WITH CURATIVE INTENT 25% 13

14 ADDED BENEFIT 36 NEW CANCERS DISCOVERED DURING FOLLOW UP IN 35 PATIENTS HALF IN THE AERODIGESTIVE TRACT RESULTANT FOLLOW-UP REGIMEN 2 VISITS 6 MONTHS APART YEARLY VISITS THEREAFTER PHYSICAL EXAM AND CHEST X-RAY 14

15 ST LOUIS VA FOLLOW UP STUDY NON INTENSIVE 120 INTENSIVE NO OUTCOME DIFFERENCE SAO PAULO BRAZIL PATIENTS SEEN FOR SYMPTOMS <4 SCHEDULED VISITS IN 2 YRS 15

16 PATIENTS SAO PAULO, BRAZIL 2 YEAR FOLLOW UP ROUTINE PHYSICAL EXAM Q 2 MONTHS CHEST X-RAY Q 4 MONTHS CHEST CT Q 6 MONTHS LIVER FUNCTIONS Q 12 MONTHS FINDINGS SYMPTOMS IDENTIFIED MOST RECURRENCES IN BOTH GROUPS PROGRESSION FREE SURVIVAL NOT DIFRERENT BETWEEN GROUPS NO SURVIVAL DIFFERENCE AFTER RECURRENCE BETWEEN GROUPS 16

17 ADDED BENEFIT HOSPITALIZATIONS FOR UNRELATED CONDITIONS AND DAILY COST LOWER FOR STRICT FOLLOW UP GROUP THAN SYMPTOM GROUP STUDY CONCLUSIONS COST DIFFERENCE SIGNIFICANT (<0.001) VALUE OF STRICT FOLLOW UP METHOD QUESTIONED 17

18 BESANCON FEASIBILITY TRIAL VISIT AND CXR EVERY 3 MONTHS BRONCH AND CT EVERY 6 MONTHS 192 PATIENTS, 136 RECURRED 26% ASYMPTOMATIC ASYMPTOMATIC RECURRENCE DISCOVERY CHEST X-RAY OR EXAM 33% CT SCAN 38% BRONCHOSCOPY 29% 18

19 FRENCH STUDY 43% ASYMPTOMATIC AND 17% SYMPTOMATIC RECURRENCES TREATED WITH CURATIVE INTENT LEAD TIME BIAS NOTED WITH NO DIFFERENCE IN OVERALL OUTCOME ADDED BENEFIT 11% OF PATIENTS HAD NEW CANCERS DETECTED DURING FOLLOW UP 50% IN AERODIGESTIVE TRACT 19

20 CONCLUSION NO STATISTICALLY SIGNIFICANT SURVIVAL BENEFIT FOR THOSE WITH RECURRENCES DETECTED BY FOLLOW UP ROUTINE VS SYMPTOMS THE SCIENCE OF FOLLOW UP NO EVIDENCE THAT A FOLLOW-UP ROUTINE FOR LUNG CANCER PATIENTS AFTER POTENTIALLY CURATIVE THERAPY IMPROVES SURVIVAL 20

21 LUNG CANCER TREATMENT GUIDELINES FIRST PUBLISHED 1996 NCCN AND ESMO UPDATED Q 1-2 YRS SOME DO NOT INCLUDE FOLLOW UP ROUTINE GUIDELINES FOLLOW UP GUIDELINES ASCO H&P Q 3 MONTHS ACR & ACCP CT Q YEAR ESMO H&P AND CT Q 6 MO X 2 YR NCCN CT Q 6 12 MO X 2 YR; YEARLY 21

22 SHOULD A FOLLOW-UP ROUTINE BE USED? WHAT DOES THE SCIENCE SAY? THERE ARE PROS AND CONS ROUTINE FOLLOW-UP CONS NO EVIDENCE THAT FOLLOW-UP ROUTINES INFLUENCE OUTCOME EVIDENCE BASED FOLLOWUP GUIDELINES UNAVAILABLE CURRENT GUIDELINES CONFLICTING FOLLOW -UP ROUTINES COSTLY 22

23 ROUTINE FOLLOW-UP PROS 10% DEVELOP NEW CANCERS 1-2% RISK/YEAR OF 2 ND LUNG CANCER EXPENSE OF CO-MORBIDITY MANAGEMENT MAY BE DECREASED THE ART OF FOLLOW UP PROVIDESINTANGIBLE BENEFITS IMPROVE OVERALL MEDICAL CARE CORRECT WRONGLY INTERPRETED SYMPTOMS 23

24 THE ART PROVIDE FEEDBACK ON TREATMENT OUTCOME REDUCE PERCEIVED MEDICAL-LEGAL RISKS STRENGTHEN DOCTOR PATIENT RELATIONSHIP WHAT IS THE HEALTH CARE PROVIDER TO DO? MUST WE CHOOSE BETWEEN THE ART AND THE SCIENCE? 24

25 Leonardo da Vinci RENAISSANCE MAN MOST DIVERSELY TALENTED MAN WHO EVER LIVED ART IS SCIENCE AND SCIENCE IS ART ART AND SCIENCE THE HEALTH CARE PROVIDER CURRENTLY DETERMINES THE BEST FOLLOW UP REGIMEN FOR THE INDIVIDUAL PATIENT 25

26 IN THE FUTURE THIRD PARTY PAYORS MAY DICTATE THE FOLLOW-UP REGIMEN BASED ON VALUE ADDED 26