Dosages - 1268028

There is no study to speak to this. We need to reduce dose to the point that it's safe. If this is in a setting of adjuvant therapy, it's especially important for treatment to be safe, since patients may already be cured. A subset analysis of the Canadian BR.10 trial showed that patients who stopped treatment after fewer than 4 cycles due to side effects or just refusing to continue did just as well as the patients who received a full 4 cycles.

I am not aware of evidence that shows that patients who undergo dose reductions do significantly worse than patients who don't.

Good luck.

-Dr. West

Hi lablady,

Most oncologists do not follow up with monthly scans when a patient has had good results for 18 months or longer, and most typically use CTs. The resolution of an x ray is such that they are unlikely to reveal small changes with any accuracy. As Dr. West has said:

”My personal view is that a chest x-ray is about as useful as just looking at a person. You’re probably as likely to find someone is progressing by seeing that they look unwell as by finding progression on an x-ray, a technology that is over a century old. While I consider a PET scan an exceptionally sensitive way to detect progression, arguably too sensitive, I see a chest x-ray as an almost disingenuous way to do surveillance for progression. It’s so insensitive for anything short of striking progression that it seems like something just done as a ritual to be doing something that seems almost like doing a meaningful test. There’s no evidence it helps more than just seeing a person in the clinic and monitoring for symptom changes, and I really think it mostly just humors everyone into feeling like imaging is being done. To be frank, I really think of it as the placebo arm of a study of meaningful follow-up.

I don’t mean to say that I never do a chest x-ray, because they can be helpful for certain questions, and they’re easy and low radiation, but they really aren’t very helpful in determining whether there’s mild progression of a cancer being treated.” – http://cancergrace.org/topic/x-ray-or-petct#post-1253206

"He also stated "I should really qualify my comments by saying that this is an area in which style and judgment prevail. My approach is not the only way to think of these issues, and other approaches are not wrong." - http://cancergrace.org/topic/on-crizotinib-frequency-of-x-ray-question#…

JimC
Forum moderator

Jim covered the highlights. There is really no evidence that post-treatment surveillance improves survival at all, but we all do it, and recommendations and conventions aren't based on evidence as much as best judgment.

The quotes Jim extracted really capture my true view on it. Chest x-rays are a great way to pretend people are doing something valuable, but it's hard to maintain that pretense when we think that chest x-rays were a solid technology 100 years ago. My personal view is that a low dose screening CT provides incredibly greater information with still very limited radiation. Knowing there is no truly evidence-based approach of proven superiority, my judgment is that a chest x-ray is so insensitive that it's essentially disingenuous to use that an expect to find something in a timely enough way to make a difference.

-Dr. West

Hi lablady, I hope your husband is cured and all the scans are clear. Like so many things how often to scan is a judgement call. After a year without treatment or progression CT scans are often taken every 6 months, moving to once a year at some point, at least by year 5 at which time he will be considered cured. Then a scan once a year since at that point a person is considered at higher risk of a new primary cancer than a person whose never had cancer. But let's see what our experts say.

All best,
Janine

It would be typical to get a CT every 6 months or so after the first year, then transition to annual scans maybe 4-5 years after surgery. However, as I said, there is no evidence that anyone lives longer due to doing this scan schedule. We do it for the same reason you outlined -- mostly anxiety and a compulsion to all (patients and doctors) feel that we're being proactive. Are there occasional patients we catch with a curable local recurrence or new early lung cancer? Yes, from time to time, but we don't have evidence that these practices improve survival in any meaningful way.

With that in mind, I can't say what's reasonable. Part of it depends on anxiety and peace of mind provided by more "aggressive" surveillance. The fact is that 90% of the Canadian population lives within 100 miles of the US border, so the US health care system and the ability to decompress the Canadian system by supplementing the provided care with additional purchased interventions is part of how the Canadian system works. Of course, there are many US facilities just a short ride off of the interstate from Canada that are happy to provide the Canada-denied interventions. Roswell Park in Buffalo is certainly an excellent center, and most screening low-dose CT scans are priced competitively to lower the barriers for screening high risk patients, so that's an option to consider -- but to be fair I need to underscore that I think it's more likely to be a treatment for anxiety than a cure for early or recurrent cancer.

-Dr. West

Hi all
a Canadian oncologist opinion sliding in a bit late here - but i'll put in my two cents, which is about 1.4 cents US.

Though it may be tough to hear, I think we have to differentiate the two reasons we follow patients after curative surgery and chemotherapy. The first is to catch the cancer if it comes back (recurs) and unfortunately if it does come back it is highly unlikely that it could be cured again. So if someone is followed by regular clinic visits and maybe x-rays, one can catch the recurrence at the time at which someone begins to notice symptoms and at that point start treatment. We don't tend to start treatment for a tiny recurrence with no symptoms that is picked up only on CT, though that can be debated. So if a cancer has come back and cannot be cured as long as the person does receive some treatment and is followed, catching it early does not improve survival (statistically) and that is why there is no standard follow up for CT scans. There is considerable variablity between getting CT's every 6-12 months or almost none at all, and neither is "right". In Canada, most of us follow the CT and follow up protocol outlined in the clinical trials that demonstrated a benefit to adjuvant chemo (which was a Candian trial of course).

The second reason we follow patients after curative surgery is to catch a brand new primary lung cancer. This is different than a recurrence because sometimes this CAN be cured and in this case it would be better to catch it early. This is the rationale many of us use to do routine CTs, to catch a new one and cure that too.

Clearly everyone is different, and anxiety management is critical. If you want to pay for extra CT scans in private Candian clinics or a trip to the USA you are most welcome to. However - you may want to consider the potential anxiety that comes along with finding tiny non-specific abnormalities on these CTs because that is very common, you might want to read posts on that too.
Best of luck!

I have to add my 2 cents as well. My new onc since my local recurrence (stage IIIA) July 2013 for which I had surgery and adjuvant chemo says that my CT scan next week will be my last. Then she'll alternate between xrays and CT's. I explained to her that when I was first dx, the xray only saw one tumor but the CT scan picked up the second one. And since I've had radiation and surgery with chemo both times, I'm not comfortable using xrays at all, too much scarring. Of course I'm on Medicare so I'll have to see what their protocol is as far as CT scans go. Anyone know? Take care, Judy
P.S. I only have a new onc since my first one passed away.

Regular CT scans are still routinely covered for surveillance by Medicare. I don't necessarily that a chest x-ray is bad if CT scans are still being done. It's not that a CT alternating with a chest x-ray every 3 months or so is a bad strategy for the first year or two out from chemoradiation, and in fact I'm sure many good oncologists do this (I say that because I used to favor this approach). But then I realized that the chest x-ray didn't really add any meaningful information and that I really just relied on the CT scan every 6 months. Sometimes I have the patient come in half way between them just to check that they're feeling well and have no new symptoms that would lead me to favor getting a scan sooner.

This is all well in the range of judgment -- there is really no wrong answer, and I think subtle differences in how "high risk" a person is, combined with their level of anxiety about needing close follow-up vs. wanting to move on with their lives can shape the recommendations even from the same oncologist. I think chest x-rays add little helpful information, especially in people who have abnormal lungs already from surgery and/or radiation-induced scarring. I think we rely on them more for a pretense of doing something active (not meant to be duping a patient, just trying to reassure ourselves as doctors, as well as patients) than for the clear value they add in a surveillance setting.

-Dr. West

As Dr West has said this is a variety of approaches to follow up, when a variety exists it means there is no right or wrong approach. You can see when we "know" something is a good idea based on evidence there is little variety, for example the recommendation for surgery or adjuvant chemotherapy, but there is no evidenced-based standard for how patients are followed. This is ok, as oncologists we are used to working in the realm of less certainty, but this is why there is a long discussion about this topic.

I rarely disagree with Dr West, but i do find that intermittent chest x-rays are useful, in part because we are "doing" something but also because i have occasionally picked up a change that was not yet associated with symptoms, this probably doesn't make a huge difference in the long run because eventually i will either get a CT (at the next visit) or symptoms will develop that i will chase down with a scan. so, perhaps it is just a habit to do an x-ray, but it's not one i am likely to lose.

In response to your question about the trial recommendations for follow up after adjuvant therapy - this was the Canadian study (BR10) published in the New Engalnd Journal of Medicine in 2005; the suggested follow up was "chest radiography every 3 months for the first three years and then every 6 months thereafter". Chest radiography does actually mean chest x-ray. So this is why people feel ok about only doing x-rays. But 2005 was a long time ago and with low dose CT scanners many oncologists have moved to CTs every 6-12 months.

As i said before, it's all about anxiety and for some it's related to "bad" past experiences with x-rays, for others it's related to anxiety generated by following small non-specific nodules seen on the CT but too small to characterize so they are just monitored.

This is good to hear - you are in excellent hands with Dr Juergens, and she can give you both a USA and Canadian perspective as you likely know she moved to Hamilton from Johns Hopkins.

I am always a strong trial advocate, this is one we have open as well and you are right we don't have a lot of trials in the adjuvant setting these days. At the very least you get very close follow-up, yes it's a little more time consuming but overall i find the extra attention helps diminish anxiety at all levels.

Best of luck

I agree that this is a very compelling clinical trial option. I also know Dr. Juergens, who has done some video content here on GRACE and is definitely an expert in whom you should have confidence.

And like Dr. Laskin, I am always happy to favor a trial option that improves our understanding and may lead to improved outcomes for lung cancer in the future.

Good luck.

-Dr. West