GRACE :: Lung Cancer
Dr West

When Do Recurrences of Lung Cancer Happen After Surgery?

Share
download as a pdf file Download PDF of this page

The answer is, “Usually pretty early”. I tell my patients that the risk is “front-loaded”, meaning that we typically see recurrences occur in the first couple of years after curative therapy for lung cancer, if they’re going to happen at all. That said, I haven’t seen a lot of data that actually illustrates the point, but there was a presentation at ASCO this past year that addressed how well recurrences/disease-free survival predict overall survival after surgery for resectable NSCLC. Not surprisingly, there was a very good correlation, though it wasn’t perfect (patients can die from side effects of the treatment, or from unrelated but competing medical problems).

In the process of reviewing the data from two “meta-analyses” of multiple smaller studies of chemotherapy after surgery, either with or without radiation also administered, a group led by Dr. Michiels from Institute Gustave-Roussy in Villejuif, France reported on the “lead time” that diseease-free survival gives in predicting overall survival. They found that, if recurrences were going to ever happen, about 50% occurred within the first year, at least two-thirds within two years, and about 80% or more within three years.

time-to-recurrence-in-early-stage-nsclc (click on image to enlarge)

This really corroborates the experience of clinicians caring for patients after surgery. Once you get out 2-3 years after surgery, odds are decidedly in your favor, with declining risk of ever seeing a recurrence if it hasn’t happened within that time. Though the authors didn’t report on the data with greater specificity, I strongly suspect that the data would show that patients with higher stage disease (stages II and III, for instance) are even more likely to recur early or not at all, while those with stage I NSCLC, especially those with smaller tumors or with cancers that we’d anticipate having more indolent behavior (bronchioloalveolar carcinoma, for instance) still having a risk that stretches out for years.

I don’t think I’ve seen a similar analysis of patients with locally advanced NSCLC treated with chemo/radiation, but we see the same trend of front-loaded risk there too. Almost always focusing on patients with a higher stage than resected NSCLC trials, these studies show a median DFS of about 10 months, while others are dropping out from significant side effects and even a 5-7% treatment-related death rate in the more aggressive chemo/radiation trials (and these are in more selected patients than the broader population in the real world, many of whom wouldn’t be eligible for such trials). A just-published trial of new non-surgical strategies for stage III NSCLC used OS 18 months after enrollment/start of treatment as the predictor of the efficacy of the strategy.

Clearly, the take-home message is that the risk of recurrence/progression for most patients with potentially curable lung cancer — and this applies to limited disease small cell lung cancer as well — is primarily focused in the first 12-24 months, diminishing thereafter. How early the peak risk is, and how long the tail of recurrence risk goes out, is largely related to the aggressiveness of the underlying cancer.


36 Responses to When Do Recurrences of Lung Cancer Happen After Surgery?

  • mimiphan says:

    Hi Dr. West,

    Thank you for the posting this information. I have a question – You wrote “almost always focusing on patients with a higher stage than resected NSCLC trials, these studies show a median DFS of about 10 months…” Does the igher stage refer to Stage III resected NSCLC? Also, is DFS counted starting from the last treatment or after surgery?

    Thank you in advance for your response.

    Mimi

  • Dr West
    Dr West says:

    What I meant to say was that adjuvant therapy trials are for a population that has only a minority with stage III disease, with many as stage I and II, while the chemo/radiation trials are usually specifically for patients with stage III NSCLC. So it’s no surprise that the median time to recurrence is shorter for a population of higher risk, higher stage patients.

    And DFS is measured from the time of randomization to observation or chemotherapy, so this would have been several weeks after surgery.

    -Dr. West

  • graceabchen says:

    Dr. West: Thank you for discussing this important issue. I am not familiar with the plot. Does the plot show the percentage of the total number of patients who have experienced recurrences within 5 years after surgery as a function of time? If this is the case, then the plot only provides information about time frame that recurrence will comes if it comes at all in five years. Many important data are missing from the plot, including the most relevant one, i.e., what is the chance to survive 5 years without recurrence after surgery? Thanks, AB

  • Dr West
    Dr West says:

    The plot shows that, “among people who have a recurrence, when does that happen?” The median follow-up of the studies was over 6 years, which would capture the vast majority of recurrences that will ever happen.

    The question of probability of recurrence is a separate one that is discussed elsewhere, but the basic idea is that it depends on a person’s stage: the recurrence rate is in the range of 25% for patients with stage I NSCLC, 50% for patients with stage II NSCLC, and around 75% for patients with stage III NSCLC.

    -Dr. West

  • graceabchen says:

    Dr. West, Thank you very much for providing so much useful information so quickly. AB

  • UneasyRider says:

    Thanks, Dr. West. That post makes my day since I’m now 3 1/2 years past surgery.

  • Dr West
    Dr West says:

    Congratulations! It’s really gratifying to have follow-up visits become an occasion for victory laps and congratulations rather than major anxiety, as people move further and further away from the time of highest risk.

  • pmharper says:

    Don’t actually have a question (or I should say I really do have a question but won’t ask it here since I am scheduled for a regularly scheduled follow-up scan next Monday -01/12) I am posting because I have been experiencing mild symptoms that could indicate a recurrence after nearly 4 years of NED. I have kept these symptoms to myself for the last 6 weeks or so because I can see no reason to cause my family anxiety perhaps un-necessarily (from my mouth to God’s ears). However, keeping this to myself has caused me so much stress that I just had to “tell” someone and this is the safest place I know. My oncologist has told me several times over the years that pain from cancer tends to be constant and gets worse as time passes, so the come and go aches and pains that I have had over these past 4 years are just the ordinary aches and pains that everyone has at some time or another. However, while the pain I am experiencing in my back, shoulders and left arm can only be described at mild (1 -2 on the pain scale) it is 24/7 although not in all 3 places at the same time.

    I had started to feel confident that I had beat the statistics so this set-back in my attitude is taking its toll on my ability to get a decent nights sleep and of course the obsessive need to scour any and every web site that talks about recurrence, degree of pain, location of pain, etc. Well 5 more days to wait but so grateful that this forum exists. I really believe the stress of dealing with cancer is as debilitating as having cancer. UGH!

  • Dr West
    Dr West says:

    I would say that while recurrences this far out are possible, they are still very unlikely, and most of the ones that occur 4 years later are indolent cancers that appear as a new nodule or two, and not as a painful solid lesion causing pain. In other words, they are far more likely to be recurrences you learn about only from a scan, rather than from cancer-related symptoms. Of course, cancer can also defy these general principles, but it’s unlikely enough that I would at least caution you to not conclude it’s recurrent cancer until a scan shows that’s likely (and a biopsy would confirm it).

    I’m sorry, and I’d say that your point about dealing with the stress of cancer is very real. There are many people here who understand exactly what you are feeling.

    Good luck.

    -Dr. West

  • pmharper says:

    Do you realize that just having you respond ….almost regardless of what you say, is so comforting. It’s as if you were reaching out and patting my shoulder and saying…”It’s OK. Don’t worry too much.” Thank you!

  • polapony says:

    Dear Dr. West-
    Like most people who’ve had a cancer diagnosis I go online hunting for info that, in the words of a wise friend, will “prove I’m going to live forever.” This post of yours is exactly the sort of thing that gives solace at times like this, right before my two and a half year CT scan. The only glitch for me is that line about small stage 1 cancers having a risk that stretches out for years. I know I am very lucky to have had my adenocarcinoma (acinar with focal micropapillary features) found and removed when it was only 16 mm. My nodes were clear and I’ve had clear scans so far, and have been assuming that my risk of recurrence is going down with every clear scan, but are you saying that with a nodule as small as mine the risk of recurrence does not go down? Or that while it goes down it never quite goes away? Can you add any additional info for those of us in the lucky minority?

  • z3k3 says:

    Wow, Polapony, your comments mirror my thoughts almost exactly! I’ve recently had a clear two-year scan after lobectomy for a 3 cm Stage 1b adenocarcinoma with partial BAC features, and no nodes, am still on a six-month scan schedule for another year. Definitely noticed that line by Dr. West about small stage 1 cancer risk stretching out for years… Looking forward to the doc’s reply!

  • Dr West
    Dr West says:

    The risk goes down, but the risk is less “front-loaded” with lower risk cancer. If you have stage III NSCLC, the cancer usually recurs in the first 12-18 months or not at all. Most patients with stage I NSCLC are cured, but the risk is distributed more over time…still, it goes down with each scan. One critical additional piece to note is that any cancer that takes 4-10 years to recur has already demonstrated that it is following a very unusual, indolent time line that would lead me to be very careful about not over-reacting. A cancer that takes years to return in any visible form may take decades to actually cause clinical problems, let alone threaten survival.

  • polapony says:

    Thanks, doctor. Your posts have really helped me from the start; it’s an honor to get your reply.

  • donnamk1955 says:

    I was diagnosed with lung cancer in 2005 adenocarcinoma had my upper left lung lobe removed went on a adjunctive chemo taxol and carboplatin in 2010 ct showed a small speculated nodular in upper right lobe Doc said we would watch it in 2011 it had grown lit up on a pet scan went back to my first surgeon he did a wedge resection said it was granulomas 3 months later ct scan shows it is still there unchanged (crazy right) so I had a needle biopsy done 2012 & 2013 not enough tissue 8/2014 it has continued to grown still less that 2cmm I was having trouble breathing the did a hr ct in November and a pet scan it has enlarged lit up along with some fibrous tissue consolidating along the base line of my lower right lobe. Finally met a thoracic surgeon that says we need to get this out before it kills you January 16 yes 2 week ago I had an upper right lobectomy ouch!!! it was moderate differential adenocarcinoma he remove 10 lymph node all clear he said that the traces that lit up in my lower lung could be infectious of nature I am confused about chemo should I go on the second line chemo as I feel I must be high risk of reassurance and already did the carb/ taxol any words of advise would be so appreciated I have not read any cases quite like mine thanks so much in advance

  • Dr West
    Dr West says:

    I’m sorry to hear about all you’ve been through.

    There is no anticipated value for chemo in someone with a node-negative resected non-small cell lung cancer that is less than 4 cm. There is some suggestive evidence that it is associated with harm.

    Good luck.

    -Dr. West

  • donnamk1955 says:

    Thank you for your response I wish you had the magic drug for me I am so very confused my surgeon was of course able to remove the speculated mass but the other comment on my pet scan was subtly hypermetabolic consolidation involving the medial right upper and posterior right lower lobes which I seen it looks like lines across the base of my lung they say it could be infectious in nature there was no way to biopsy that he said it is the same as my upper right does that mean that could grow and come back as we both know I am all out of surgical options I am so lucky to have pulled through the first time I was 49 given 5years I got 10 now I have had my second surgery and yes I still want to do all I can. Cancer has just taken so many in my family my little brother at 29 lung end stage before we found it several cousins never turning 40 We were a farm family in Rhode Island I feel it was the pesticides used on the corn who knows ? I don’t go to my oncologist until March so I have to ask what type of harm do you refer to and is there any available trials that you know of for people in my situation I am scared it is hard to sit and wait Thank you and I am sorry to be a pest

  • Dr West
    Dr West says:

    The harm I referred to is that there is a trend in several trials of patients with earlier stage, lower risk disease to have a greater risk of dying if they received chemotherapy after surgery than if they didn’t. There is always some risk with chemotherapy, which is offset if the risk is high enough of the cancer recurring, but if not, the most aggressive approach is not necessarily the best. It may well lead to a worse chance of survival. MORE IS NOT ALWAYS BETTER.

    -Dr. West

  • Dr West
    Dr West says:

    It’s also important to underscore that neither I nor your surgeon nor anyone can guarantee that the cancer won’t recur, especially if the ambiguous findings on the scans now actually represent cancer. However, if those areas are cancer, doing chemotherapy now won’t cure it. So if you do chemo for ambiguous lesions, I think the most likely thing is that you’ll be over-treating because the suspicious findings aren’t really cancer, or you’ll be over-treating because they re actually cancer that is so minimal and so slowly growing that there is no advantage to treating long before it’s necessary.

    Good luck.

    -Dr. West

  • donnamk1955 says:

    thank you so much for all your information it means more that you know to have the time to really step back heal from surgery and know that it is not a time bomb ticking away inside me I just told my husband I am going to take a deep breath heal from surgery and approach this later. Of course my cancer monster will always be in my closet but every once in awhile I get to be just a mom wife and grandmother just like everyone else.

  • Teresa says:

    Dr. West,

    I am coming up on being 5 Year Survivor of Stage 2 NSCLC. I usually try to stay away from looking at statistics, but I was glad to find this and read your response to the comments and questions regarding reoccurence. I had a Pneumonectomy followed by adjuv. chemo and have been cancer free since surgery Sept 2010. Regardless of how much faith I have I will always have that uncertianty now so i try to keep up with what is going on the world of lung cancer….

    Teresa

  • aussieguy
    aussieguy says:

    Just a quick question, when does the clock start ticking ? I had surgery in feb but it will be around August when I finish treatment ( adjuvant chemo and radiation to mediastinum) so by the end of it I will be 6 months post surgery ..

  • Dr West
    Dr West says:

    This is time since surgery.

  • aussieguy
    aussieguy says:

    Thankyou dr West

  • monervamom says:

    This is such an encouraging post. I am 3 years and two months out from surgery for stage 3A squamous. No evidence since then. I had chemo and radiation too. It is wonderful to hear how the odds a finally in my favor.
    Thanks for the posts.

  • aussieguy
    aussieguy says:

    I wish I had paid more attention during statistics but the way I am reading it you odds are in your favour after the first year ..

  • Dr West
    Dr West says:

    Yes, the basic idea is that the risk of recurrence is very “front-loaded”, declining pretty rapidly after the first 1-2 years.

    Good luck.

    -Dr.West

  • abil85 says:

    Thank you for a wonderful blog , I’m from Norway so please excuse the bad English .

    Do I understand correct: that if you have stage 3 non operable lung cancer it is about 27% chance the cancer will recurring after 2years with stable disease ?

  • Dr West
    Dr West says:

    I would say that’s about right, or the recurrence rate with stage 3 could be even lower if there hasn’t been progression 2 years after chemo and radiation. The higher the stage, the more likely that recurrence will happen early or not at all.

    I’ve seen recurrences happen more than 2 years after chemo and radiation, but the majority of the patients who make it that far out without any evidence of progression are the patients I’m still seeing 3-5 or more years out, with no evidence of active disease.

    Good luck.

    -Dr. West

  • abil85 says:

    Thank you so much for you answer, it means a lot. We are now 21 months out. We are in a studie for the cancer vaccine named UV, its a synthetic peptide vaccine. The second generation of gv1001 vaccine.

  • abil85 says:

    If you have stage 3 non operable lung cancer and have had a stabel disease for 5 years, can you then be called “cancer-free” I have heard that when you have stage 3 you have a chronic disease…but I dont quit understand that its chronical if its stable for 5 years..

  • Dr West
    Dr West says:

    Yes, it is common to have residual imaging abnormalities after chemo and radiation, but if it hasn’t progressed over many years, it’s overwhelmingly likely that there is NO viable cancer and that the treatment has been curative. I suppose it would be remotely possible that a stage 3 cancer could recur more than 5 years out, but it would be extremely unlikely. It would be more likely that any evidence of active cancer is from a new, separate cancer than a recurrence of the prior one.

    I tell my patients that I consider them cured of their cancer if there is no evidence of their cancer progressing/recurring by 5 years out from a stage 3 cancer.

  • joshua says:

    My wife,66 years old with COPD and a smoker untill 2008/ diagnosed poorly diff nsclc adenocarcinoma .Lobectomy RUL. Feb.2008/ Stage T2N1MO T=3.7 . Aduj chemo Cisplatine+Nevelbin ,2 courses (could not tolerate).Follow up ct scans gradual growth in nudole LLL,and in LUL (both were identified before surgery).In ct directed biopsy to the left tumor June.2011: Adenocarcinoma of the lung.Targeted Radiation to LUL. (SBRT) 5000rd. and RFA to LLL Follow up ct scans every 3 months. March 2016 tumor increased by 1 cm. (3.8 x2.2) and 3 cm. the other. PET CT indicated pathalogical FDG in both tumors and FDG in lymph node in the lung gate.Genomic test Foundation One : KRA G12V;NTRK amplification,,ATM,APC,MCL1. MSI – meduim-high.PDL-1
    positive strong (50%/up) .Started Keytruda (1 infusion). In the meanwhile results from current PET CT (before 1st infusion) indicates NO PROGRESSION IN 5 MONTHS PRIOR TO KEYTRUDA. What do you suggest ? continue with tratment or stop and follow up ? Thank you so much. Joshua

  • Dr West
    Dr West says:

    I think there’s good reason to question whether you need to be on a new therapy in the absence of any evidence of progressing disease. It makes good sense to discuss this with your oncologist. It may be appropriate to continue surveillance without any therapy in the absence of clinically significant progressing disease.

    Good luck.
    -Dr. West

  • joshua says:

    Thank you very much ,I appreciate very much your quick response.
    Does your answer apply also to the fact that progression is evident in the previous ct. scan in March 2016,compared to a ct. scan 6 months earlier ?
    The no progression refers to the period,between April 2016 and July 21,2016 ?
    Thanks again

  • Dr West
    Dr West says:

    These are issues that are better discussed with your own oncologist, as I’ve not seen the scans and have none of the relevant details.

    -Dr. West

Leave a Reply

Ask Us, Q&A
Lung/Thoracic Cancer Expert Content

Archives

Share
download as a pdf file Download PDF of this page

GRACE Cancer Video Library - Lung Cancer Videos

 

2015_Immunotherapy_Forum_Videos

 

2015 Acquired Resistance in Lung Cancer Patient Forum Videos

Share
download as a pdf file Download PDF of this page

Join the GRACE Faculty

Breast Cancer Blog
Pancreatic Cancer Blog
Kidney Cancer Blog
Bladder Cancer Blog
Head/Neck Cancer Blog
Share
download as a pdf file Download PDF of this page

Subscribe to the GRACEcast Podcast on iTunes

Share
download as a pdf file Download PDF of this page

Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List icon

Subscribe to
GRACE Notes
   (Free Newsletter)

Other Resources

Share
download as a pdf file Download PDF of this page

ClinicalTrials.gov


Biomedical Learning Institute

peerview_institute_logo_243