From the GRACE Archives--Originally Published November 2, 2007 | By Dr West 

Or “What I Say vs. What I Do”

The current recommendations from the American College of Chest Physicians is for patients who underwent treatment with curative intent for lung cancer, and who are still healthy enough to be a candidate for any further aggressive treatment if needed, should undergo repeat doctor visits every six months for two years, and then annually after that. These surveillance visits should include a review of how they’re doing, physical exam, and some kind of chest imaging (chest x-ray or chest CT). Now, we know that chest CTs give a lot more detail than chest x-rays, and at least in theory more frequent visits and imaging could pick up a recurrence or new cancer earlier, but so far there isn’t any real evidence that patients who undergo very frequent surveillance do better than those who see their doctor rarely.

I personally tend to have visits about every 4 months after surgery for the first year, then every 6 months for up to four years, and then annually after that; after chemo and radiation, I will often follow patients with visits and scans every 3-4 months initially, although I can’t point to the evidence, but these patients are at high risk for recurrence, and occasionally we find a local recurrence after chemo and radiation that can undergo surgery for the solitary area of viable cancer. Is this in the guidelines? No. And I have just a couple of patients who are alive many years after initial treatment with no evidence of disease, after a surgery that followed chemo and radiation, and I honestly think they are now cured. Unfortunately, that applies to only a very small percentage of my surgical or locally advanced chemoradiation patients, but it motivates me to continue with a policy of close surveillance. And let’s be honest: even if an aggressive treatment isn’t curative, and the cancer returns in several locations after surgery or radiation to a focal area, I don’t know a patient who regrets pursuing an aggressive approach that we felt could be curative at the time.

I’ve mentioned in the limited literature on precocious metastases that there are associated with a minority of patients remaining alive 5 years later, after surgery for a single brain metastasis or adrenal gland metastasis, for instance. It may be that the aggressive, surgical approach is curative. The problems is that it may also be that there is something very different in the biology of a metastatic cancer that has only a single area of metastatic cancer vs. one that has spread all over. If the cancers that present with a single metastatic focus move far more slowly than other cancers that have multiple liver and bone or brain lesions, maybe we’re congratulating ourselves about what we’ve done, when really what we’ve done is just cherry pick the people who have the best prognosis and then take credit for how they’re doing.

Several people have asked about situations of aggressive salvage surgery or radiation on the Q&A Forum section. I think you need to balance hope and desire to be aggressive with reality. I don’t believe you can be “downstaged” from stage IV and then have surgery to residual areas of disease. The “great saves” have more commonly been people with a curable stage of disease that has a single area of residual disease, not metastatic. It also makes more sense if you’ve followed a patient for months or years and are only seeing one area of cancer over a long time. Seeing a good result for the first time could still mean that it’s coming back in multiple areas the next time you look. It makes much more sense to pursue aggressive salvage strategies if time has shown there isn’t anything new that will likely pop up before the patient has recovered from surgery or radiation. And I also think it makes 10 times more sense to be aggressive against a single area of viable cancer than to do surgery on two or three areas. We’re trying to thread a needle by acting as if a single area of metastatic disease represents the ONLY area of metastatic disease. This is very rarely the case. Finally, I think it’s much more reasonable to push the envelope if the treatment can be tolerated well than if it’s going to be a life-threatening challenge. Stepping outside of typical treatment patterns is less problematic for well-tolerated focal radiation than for a right pneumonectomy. And it’s much more problematic to consider that major surgery for an 85 year-old who had a heart attack last year and is on oxygen than it is for an otherwise healthy 55 year-old.