Cosa dicono le linee guida

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DALLA TEORIA ALLA PRATICA P^RIMO C^ONSENSUS R^EGIONALE

IV sessione: carcinoma del polmone Cosa dicono le linee guida

Palmanova, 14 Maggio 2016 Dr.ssa Elena Poletto, Udine

N ^ON S ^MALL C ^ELL L ^UNG C ^ANCER

 Lung cancer is responsible for 23% of total cancer deaths in men and 11% in women globally

Jemal A et al, 2012

 Less than 20% of patients with new lung cancer diagnosis have disease amenable to curative treatment

Jemal A et al, 2008

 Poor 5-year overall survival

Goldstraw et al, 2015

N ^ON S ^MALL C ^ELL L ^UNG C ^ANCER

 From 20% to 40% of patients who underwent a complete resection for stage IA-IIB develop a locoregional or distant recurrence

Winton T, N Engl J Med, 2005 Lou F et al, J Thorac Cardiovasc Surg, 2013

 Increase of the risk for secondary primary cancer from 1% to 3% per patient per year during the first 3 years

Lou F et al, J Thorac Cardiovasc Surg, 2013

 Recurrence peaks around 9 months and at the end of 2nd and 4th year after first diagnosis

De Michel R et al, J Thor Oncol, 2013

NSCLC ^FOLLOW - ^UP : ^WHY

 To manage complication related to the curative intent therapy

 To detect symptomatic or asymptomatic recurrence of primary lung cancer

 To detect new primary lung cancer to allow potentially curative retreatment

 Surveillance for second smoking related primary tumor (eg.

head & neck, bladder…)

 Life-style raccomandations:

 Smoking cessation

 Counselling for wellness and health promotion

 Cancer screening

NSCLC ^FOLLOW - ^UP : ^WHY

The main goal is to identify early recurrence in order to improve

survival

NSCLC

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 Several studies showed that intensive follow-up vs symptoms based follow-up did not improve overall survival

Younes et al, Chest 1999 Walsh GL et al Ann Thorac Surg 1995

 Other studies showed that intensive follow-up is effective: patients with asymptomatic recurrence have better overall survival

Westeel et al Ann Thorac Surg 2000

NSCLC

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Decreto Lorenzin

NSCLC

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Physical examination

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Instrumental exams

 Chest Xray

 Chest-abdomen CT scan

 CT/PET

 Brain CT/MRI scan

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Blood test



Other indications…

NSCLC

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Time from

diagnosis AIOM ESMO ACCP NCCN

<3 years Every 3-6 moths

Every 6 month

Every 6 months

Every 3-6 months

>3 years Yearly Yearly Yearly Yearly

NSCLC

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CT

Time from

diagnosis AIOM ESMO ACCP NCCN

<2 years Every 6 months

Every 6 months

Every 6 months

Every 6 months

> 2 years Yearly Yearly Yearly Yearly

NSCLC

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Organization Summary racommendations

AIOM Not reported

ESMO Not reported

ACCP Not recommended

NCCN Not reported

NSCLC

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Organization Summary recommendations

AIOM Not recommended

ESMO Not reported

ACCP Not recommended

NCCN Not reported

NSCLC

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: CT/PET

Organization Summary recommendations

AIOM Not recommended in asymptomatic patients

ESMO Not recommended

ACCP Not recommended in asymptomatic patients

NCCN Not recommended in asymptomatic patients

NSCLC ^FOLLOW - ^UP : BRONCOSCOPY

 AIOM:

 After 1 year

 High risk for stump recurrence:

 tumor-free bronchus margin <1 cm or nodal disease

 with bronchial dysplasia or carcinoma in situ

 ESMO: not reported

 ACCP:

 Every 3 months during first year then every 6 months until 5 years from curative treatment

 Patients with early central airway squamous cell

 NCCN: not reported

NSCLC

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AIOM, ESMO, ACCP and NCCN all suggest:

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Smoking cessation

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AIOM and NCCN:

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Annual influenza and pneumococcal vaccination

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Counselling for wellness and health promotion

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Cancer screening

NSCLC

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 Physical examination: not included/reported

 Chest CT scan: not included/reported

 Brain CT/MRI scan: not included/reported

 Broncoscopy: not included/reported

 CT/PET: allowed for

 dd between tumor recurrence and post-RT fibrosis;

 restaging in case of clinical-instrumental recurrence suspicion

NSCLC

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 Blood test:

 AST/ALT → routinely not indicated; only if hepatic disease suspected

 Alkaline phosphatase: → routinely not indicated; only if cholestatic hepatic or bone disease suspected

 Sodium/potassium: → routinely not indicated; only if renal disease or electrolyte disorders suspected

 Calcium: → indicated for diagnosis and screening

 Markers:

 CEA, CA 19.9: allowed for monitoring disease

NSCLC

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I (ADJ) - III; IV NED, AFTER CURATIVE TREATMENT

Time from diagnosis

Physical examination

Imaging

Chest/abdomen CT scan

Blood test

6 months x x x

12 months x x x

18 months x x x

24 months x x x

30 months x x x

36 months x x x

42 months

48 months x x x

54 months

60 months x x x

< 60 months Consider follow up by General Practicioner

NSCLC

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STAGE IV AFTER FIRST LINE TREATMENT

Time from diagnosis

Physical examination

Imaging

Chest/abdomen CT scan

Blood test

4 months x x x

8 months x x x

12 months x x x

18 months x x x

24 months x x x

30 months x x x

36 months

Follow-up as for stage I-III disease 42 months

48 months 54 months 60 months

< 60 months

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 Education for early detection of suspicious symptoms

 Smoking cessation

 Promotion of healthy lifestyle

 Influenza and pneumococcal vaccination

 Reccomend cancer screening program adhesion (eg mammography, PAP test, fecal blood test…)

 Broncoscopy after 12 months from surgery if central tumors and/or tumor-free bronchus margin <1 cm or bronchial dysplasia/carcinoma in situ

 NOT INDICATED:

 Tumor markers (eg CEA)

 Abdomen ultrasound

 18FDG CT/PET

 Brain CT/MRI scan

 Echocardiography

NSCLC

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 Stage IV NSCLC NED: same follow-up as stage I-III disease?

 Which follow up for abnormal chest CT scan findings?

 Role of multidisciplinary team:

 should stage I-II NSCLC followed by surgeons?

 Role of the radiotherapist in case of combined CT-RT treatment?

 Is reasonable continuation of follow up by general practioner after 5 years from NSCLC treatment?

 Is reasonable to tailor follow up according to patients’ comorbidity and chances to receive other curative treatments?

SCLC

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 5 years survival 4,8%

 Is follow up useful?

 Follow-up goal: to detect recurrence early while the patient still has a good PS

 ESMO/NCCN guidelines:

 CT-scans every 2-3 months in patients with metastatic disease potentially qualifyng for further treatment

 CT-scans every 3-6 month for 2 years in patient with

localized disease who have received potentially curative treatment

 Smoking cessation

N EUROENDOCRINE BRONCHIAL TUMORS

 Typical and atypical carcinoid

 Patient treated with curative intent:

 Long follow-up up to 15 years from diagnosis

 Tumor biomarker (chromogranin A and NSE) every 3-6 months

 CT scan every 2-3 years for typical carcinoid and yearly for atypical

 Patient with metastatic disease:

 CT scan and tumor biomarkers every 3-6 months during systemic treatment

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